There are two main types of lung cancer: non-small cell lung cancer, or NSCLC, and small cell lung cancer, or SCLC. NSCLC includes large cell and squamous cell carcinomas and adenocarcinoma and accounts for 80% to 85% of lung cancers. Accounting for 10% to 15% of all lung cancers, SCLC also is called “oat cell cancer” and tends to grow and spread faster than NSCLC. Other subtypes of NSCLC, such as adenosquamous and sarcomatoid carcinomas, are much less common.

Lung Cancer Risk Factors

While a reduction in tobacco smoking is one reason for positive changes in lung cancer rates, there are many other risk factors including exposure to secondhand smoke; use of beta-carotene supplements by heavy smokers; family history of  lung cancer; HIV/AIDS infection; and environmental risk factors such as radiation therapy, imaging tests including CT scans and radon exposure.

Although supplementing with beta carotene is a risk factor for people who smoke, there is evidence that eating more foods containing carotenoids can help decrease lung cancer risk. Studies have shown an inverse relationship between the consumption of a combination of fruit and vegetables and a lower risk of lung cancer. The same protective relationship has been associated with higher fruit intake, but studies evaluating vegetable consumption have yielded inconsistent results. Other research shows that a traditional Mediterranean dietary pattern may lower risk of developing lung cancer and that foods containing isoflavones may decrease risk in people who have never smoked. Limited research suggests those who are physically active may have a decreased risk of lung cancer.

Role of RDNs

Since both diet and physical activity may play a role in decreasing the risk of lung cancer, registered dietitian nutritionists can guide patients and clients regarding interventions and advice related to food, nutrition, dietary supplements and lifestyle factors. RDNs are critical members of the interdisciplinary cancer health care team and should assess patients with lung cancer diagnoses for malnutrition. Evidence has shown positive outcomes when RDNs provide medical nutrition therapy to adult cancer patients who are undergoing chemotherapy or radiation treatment. Nutritional interventions — especially during treatment — are key, and RDNs play a crucial role in helping to manage any potential side effects.

According to Dolores D. Guest, PhD, RD, a research assistant professor in the department of internal medicine’s division of epidemiology, biostatistics and preventive medicine at the University of New Mexico School of Medicine and director of the Behavioral Measurement and Population Science Shared Resource at the UNM Comprehensive Cancer Center, the location or type of lung cancer could cause several abnormalities and syndromes such as hypercalcemia, anemia, Cushing’s syndrome and others that need nutritional intervention. “It’s not uncommon for one thing to be resolved and another to appear,” Guest says. “Working with an RDN throughout treatment is very important for these patients.”

Oncology dietitian Tricia Cox, MS, RD, CNSC, LD, who works at Baylor Scott & White Medical Center in Dallas, Texas, explains that in her oncology research, many RDNs may have to focus their time on patients with head and neck cancer or esophageal tumors. The research Cox has helped to conduct shows RDNs are often understaffed in outpatient oncology settings and many of them must focus on the most critically ill patients. “While this is good for [critically ill] patients, RDNs are often unable to adequately see all of the patients who need to be seen,” she says. “This could include patients with lung cancer.”

While other members of the medical team serve critical roles, an RDN is qualified to understand the science of lung cancer and how treatment interplays with nutritional status. “RDNs are trained to be able to mitigate these effects in a very personal way, providing individualized advice so patients can make both incremental and overall improvements,” Guest says. Her research shows that the key role RDNs serve in treating high nutrition-risk cancer patients, such as those with lung cancer, is more appreciated by fellow oncology team members than ever before. “Oncologists and nurses really value and have come to rely on RDNs to be the experts when it comes to assessing and working with patients to meet their nutritional needs.”

Assessing Nutrition and Nutrient Needs

About 45% to 69% of people with lung cancer experience malnutrition, which is associated with reduced quality of life, increased symptom severity and shorter survival rates. Concurrent chemotherapy and radiation, radiation to the esophageal region and being classified with stage 3 or 4 cancer all increase the risk of malnutrition. Evidence supports using the Malnutrition Screening Tool to assess for malnutrition(undernutrition) in adults; the Academy and the American Society for Parenteral and Enteral Nutrition have released a joint consensus statement that serves as a guide for assessing malnutrition (undernutrition) in adults who may be at risk.

Guest emphasizes that malnutrition screening is crucial for people with lung cancer and should be conducted at diagnosis and at regular intervals using validated instruments without modifications. The Malnutrition Screening Tool and the Patient-Generated Subjective Global Assessment are both recognized by the Academy’s Evidence Analysis Library as being valid and reliable tools for “identifying malnutrition risk in adult oncology patients” and within inpatient and outpatient settings. “Nutrition issues that are addressed proactively — not reactively — set the patient up for the best possible outcome,” Guest says.

Nutrition therapy for people who have undergone treatment, such as radio or chemotherapies, is critical. Published in 2021, a systematic review of 25 studies suggests that taste function can be impaired as early as three weeks into radiotherapy treatment and can remain impaired for three to 24 months after treatment. For people undergoing chemotherapy, impaired taste function varied and was less predictable, according to the authors, and could occur within days of treatment. A few studies also included patient reports of experiencing reduced appetite and dietary intake.

In general, nutrient needs per day for those with lung cancer can range from 25 to 30 calories per kilogram of body weight and 1 to 1.5 grams of protein per kilogram of body weight. RDNs should complete ongoing nutrition assessments for patients or clients with lung cancer throughout treatment and adjust calorie and protein recommendations as needed. Pay close attention to symptoms that may impact nutrition, such as early satiety, nausea and vomiting, diarrhea or constipation, and oral problems such as altered taste, pain, dysphagia, dry mouth, problems chewing or mouth sores, as these can reduce the patient’s ability to meet nutrition needs.

Dietary Strategies

Because people with lung cancer are at an increased risk of malnutrition, RDNs can help patients and clients maintain body weight and protect lean body mass.

“Lung cancer is often diagnosed at a later stage,” Guest says. Weight loss is very common for these patients, and it can occur or be exacerbated by factors such as the location of the tumor, metastasis or treatments including surgery, radiation and chemotherapy and immunotherapy medications. “RDNs work with these patients and their caretakers or families to mitigate the effect of malnutrition on their bodies, which can help them withstand long-term treatment and improve medical outcomes and quality of life.”

Preventing severe loss of muscle mass, or sarcopenia, is a top priority. Studies have shown 47% to 61% of patients already have sarcopenia before they start chemotherapy or chemoradiation therapy, respectively, for lung cancer. Additionally, sarcopenia increases adverse outcomes and mortality rates in those with cancer and is a hallmark of cancer cachexia, which is a multifactorial syndrome often associated with reduced food intake, systemic inflammation, and catabolic metabolism characterized by weight loss greater than 5% in the past six months (not related to simple starvation) or a body mass index under 20 with any degree of weight loss more than 2%, or muscle wasting consistent with sarcopenia (as indicated by the appendicular skeletal muscle index) and any degree of weight loss more than 2%. Nutrition for any patient with cancer cachexia increases up to 35 calories per kilogram of body weight per day and up to 2.5 grams of protein per kilogram of body weight per day.

Research shows nutritional counseling can help increase food intake in people with cancer-related weight loss. Some data also shows patients who followed nutrition counseling advice while being treated for head and neck cancer experienced better health outcomes such as increased muscle mass and survival rates. Unfortunately, some studies have shown that only 50% to 61% of patients who receive nutritional counseling are able or willing to follow an RDN’s advice due to a multitude of barriers. A recent study that included “dietitian-identified barriers” for patients with advanced forms of cancer and cachexia revealed that non-symptom related barriers — such as restrictions from a prior medical diagnosis, conflicting nutrition information or lack of motivation — were cited as barriers more often than those associated with symptoms.

In one study of 310 patients with lung cancer, those with better nutritional status had better emotional and social functioning as well as less severe symptoms including fatigue, nausea, vomiting, pain, dyspnea, loss of appetite, coughing, mouth or tongue pain, difficulty swallowing and hair loss. The most significant differences between the patients with normal nutritional status compared to the patients at risk of malnutrition or considered to be malnourished (based on the Mini Nutritional Assessment questionnaire) were improvements in insomnia, diarrhea, shortness of breath, tingling in the hands or feet, and chest, arm or shoulder pain.

For people identified as at risk of or diagnosed with malnutrition, RDNs can provide education on dietary strategies such as encouraging meals and snacks dense in calories and protein and ways to meet vitamin and mineral needs. Small, frequent meals and snacks can be helpful if appetite or intake is poor. Because many patients undergoing treatment for lung cancer may have trouble swallowing or have pain in the esophagus, texture modification may be needed.

Depending on the type of treatment, tube feeding or, in some cases, parenteral nutrition may be needed. Parenteral nutrition can be used if the gastrointestinal tract is not functioning or is not accessible, such as with a blockage in the digestive tract. Artificial nutrition in the form of enteral nutrition may be warranted if a patient isn’t able to meet their needs through diet alone. Enteral nutrition should be strongly considered if the patient is unable to eat food for a week or longer or if they only meet 60% or less of their needs through food for more than two weeks. It also should be considered if the patient is malnourished and has poor oral intake. For patients with other types of cancer (such as gastrointestinal), evidence shows nutrition interventions including modified oral diets and parenteral and enteral nutrition have the potential to not only improve outcomes, but also generate millions of dollars in cost savings annually.

Dietary Supplements

Especially for those at risk for malnutrition and not meeting nutrient needs through food, it is wise to educate patients on appropriate and safe use of dietary supplements when warranted.

Omega-3 Fatty Acids

Omega-3 fatty acid supplementation may be helpful in maintaining weight and muscle mass, especially for those with advanced NSCLC undergoing chemotherapy. Potential benefits of omega-3 fatty acid supplements for those with lung cancer may include reduced inflammation and less severity of chemotherapy-induced oral and esophageal mucositis. However, more research is needed. Additional benefits include a potential reduction of peripheral neuropathy from chemotherapy drugs or increased effects/clinical benefits of other medications used in cancer treatment.

Possible Risks of Antioxidant Supplements

Research has shown that taking beta-carotene supplements increases the risk of lung cancer in people who smoke, especially one or more packs per day. Risk is further compounded in people who smoke and drink one or more alcoholic beverages per day.

Results from animal studies show that supplementing with N-acetylcysteine, or NAC, accelerates tumor progression, but more research is needed to support these findings in humans. Other studies indicate that both NAC and antioxidant vitamin E may promote cancer metastasis because they reduce the natural reactive oxygen species that cancer cells produce, which opens a path to tumor progression. This has been shown in both human and mouse lung cancer cell study models

Also, antioxidants may reduce enzyme activity designed to promote apoptosis (the process of programmed cell death). Conversely, some research on NAC based on in vitro studies with bromelain and gastrointestinal cancer cells indicates NAC may be used to enhance the cytotoxic effects of chemotherapy drugs while protecting host tissues from the drugs’ toxicity. However, supplements that contain NAC are technically illegal at this time due to being excluded from the Federal Food, Drug, and Cosmetic Act’s definition of a dietary supplement. NAC is available as a prescription drug, and the U.S. Food and Drug Administration is evaluating whether certain NAC-containing products can be lawfully marketed as dietary supplements in the future. The Natural Medicines database by TRC Healthcare also indicates NAC is currently “considered an unlawful ingredient in dietary supplements” and is “likely ineffective” for lung cancer.

The Vital Role of RDNs on the Cancer Care Team

RDNs working with lung cancer patients can provide nutritional counseling, supplement guidance and lifestyle modification suggestions to help improve outcomes. New research and analysis published in two articles in the February 2021 Journal of the Academy of Nutrition and Dietetics highlight the role nutrition may play in cancer risk and treatment, as well as the barriers cancer survivors face in maintaining a healthful diet.

According to one of the articles, American adult lung cancer survivors with obesity (ages 30 to 64 and current smokers) had a diet quality score that was significantly lower compared to the reference group, based on data from the National Health and Nutrition Examination Surveys from 2005 through 2016. In the study, adherence to the 2015-2020 Dietary Guidelines for Americans — specifically the dietary recommendations for whole grains, greens and beans, sodium and fatty acid — had “less than 50% of the maximum possible scores” based on the Healthy Eating Index 2015, which is a measure of diet quality. RDNs play an important role in providing nutrition education so cancer survivors can better meet these guidelines.

References

2020 Standards and Resources. The American College of Surgeons website. https://www.facs.org/quality-programs/cancer/coc/standards/2020. Updated December 6, 2016. Accessed March 25, 2022.
Cancer Stat Facts: Breast Cancer. National Institute of Health National Cancer Institute website. https://seer.cancer.gov/statfacts/html/breast.html. Accessed May 3, 2022.
Cancer Stat Facts: Lung and Bronchus Cancer. National Institute of Health National Cancer Institute website. https://seer.cancer.gov/statfacts/html/lungb.html. Accessed May 3, 2022.
Cancer Stat Facts: Prostate Cancer. National Institute of Health National Cancer Institute website. https://seer.cancer.gov/statfacts/html/prost.html. Accessed May 3, 2022.
Center for Evidence and Practice Improvement. Agency for Healthcare Research and Quality. https://www.eatrightpro.org/-/media/eatrightpro-files/news-center/on-the-pulse/regulatorycomments/academy-comments-to-ahrq-sead-nutrition-for-improved-cancer-outcomes.pdf?la=en&hash=4A8664E51C13992B1E2A9668CC912A16540E0719. Published December 1, 2021. Accessed March 25, 2022.
Du H, Cao T, Lu X, Zhang T, Luo B, Li Z. Mediterranean Diet Patterns in Relation to Lung Cancer Risk: A Meta-Analysis. Front. Nutr. 2022;9.
Ester M, Culos-Reed SN, Abdul-Razzak A, et al. Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer. 2021;21(1):1-3.
FDA Releases Draft Guidance on Enforcement Discretion for Certain NAC Products. U.S. Food and Drug Administration website. https://www.fda.gov/food/cfsan-constituent-updates/fda-releases-draft-guidance-enforcement-discretion-certain-nac-products. Accessed May 3, 2022.
Kasprzyk A, Bilmin K, Chmielewska-Ignatowicz T, et al. The role of nutritional support in malnourished patients with lung cancer. In Vivo. 2021;35(1):53-60.
Kiss N, Symons K, Hewitt J, et al. Taste Function in Adults Undergoing Cancer Radiotherapy or Chemotherapy, and Implications for Nutrition Management: A Systematic Review. J. Acad. Nutr. Diet. 2021;121(2):278-304.
Lee E, Zhu J, Velazquez J, et al. Evaluation of diet quality among American adult cancer survivors: Results from 2005-2016 National Health and Nutrition Examination Survey. J. Acad. Nutr. Diet. 2021;121(2):217-32.
Lung Cancer – Health Professional Version. National Institute of Health National Cancer Institute website. https://www.cancer.gov/types/lung/hp. Accessed March 22, 2022.
Lung Cancer Prevention (PDQ®) – Patient Version. National Institute of Health National Cancer Institute website. https://www.cancer.gov/types/lung/patient/lung-prevention-pdq. Updated August 4, 2021. Accessed March 22, 2022.
Lung Cancer. World Cancer Research Fund International website. https://www.wcrf.org/dietandcancer/lung-cancer/. Accessed March 24, 2022.
Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, & Diet Therapy 15th ed. Philadelphia, PA: W.B. Saunders; 2020:35.
Marra M, Bailey R. Position of the Academy of Nutrition and Dietetics: micronutrient supplementation. J. Acad. Nutr. Diet. 2018;118(11):2162-73.
N-Acetyl Cysteine (NAC). Natural Medicines Database website.  https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/professional.aspx?productid=1018. Accessed May 3, 2022.
Nasrah R, Van Der Borch C, Kanbalian M, et al. Defining Barriers to Implementation of Nutritional Advice in Patients with Cachexia. J Cachexia Sarcopenia Muscle. 2020;11(1)69-78.
Nigro E, Perrotta F, Scialò F, et al. Food, Nutrition, Physical Activity and Microbiota: Which Impact on Lung Cancer?. Int. J. Environ. Res. 2021;18(5):2399.
Nutrition in Cancer Care (PDQ®) – Health Professional Version. https://www.cancer.gov/about-cancer/treatment/side-effects/appetite-loss/nutrition-hp-pdq. Updated March 3, 2022. Accessed March 22, 2022.
Physical Activity and Cancer Risk. World Cancer Research Fund website. https://www.wcrf.org/diet-activity-and-cancer/risk-factors/physical-activity-and-cancer-risk/“. Accessed April 30, 2022.
Polański J, Jankowska-Polańska B, Mazur G. Relationship between nutritional status and quality of life in patients with lung cancer. Cancer Manag Res. 2021;13:1407.
Sarangarajan R, Meera S, Rukkumani R, Sankar P, Anuradha G. Antioxidants: Friend or foe?. Asian Pac. J. Trop. Med. 2017;10(12):1111-6.
Skipper A, Coltman A, Tomesko J, et al. Position of the Academy of Nutrition and Dietetics: Malnutrition (Undernutrition) Screening Tools for All Adults. Kompass Nutrition & Dietetics. 2021;1(2):38-40.
Tackling the Conundrum of Cachexia in Cancer. National Institute of Health National Cancer Institute website. https://www.cancer.gov/about-cancer/treatment/research/cachexia. Published November 1, 2011. Accessed April 22, 2022.
Ubago-Guisado E, Rodríguez-Barranco M, Ching-López A, et al. Evidence Update on the Relationship between Diet and the Most Common Cancers from the European Prospective Investigation into Cancer and Nutrition (EPIC) Study: A Systematic Review. Nutrients. 2021;13(10):3582.
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What is Lung Cancer? American Cancer Society website. https://www.cancer.org/cancer/lung-cancer/about/what-is.html. Revised October 1, 2019. Accessed April 23, 2022.
White J, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J. Acad. Nutr. Diet. 2012;112(5):730-8.
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However, recent research and newer guidelines, such as the National Kidney Foundation’s 2020 Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in CKD, created in partnership with the Academy, recommend focusing on total diet quality — which includes more plant foods. This approach, along with an individualized nutrition intervention, may be more effective at slowing progression of CKD than sticking to strict nutrient ranges.

Some research suggests eating patterns associated with better kidney health outcomes include the Mediterranean, DASH, Nordic and vegan and vegetarian diets, all of which place heavy emphasis on plant foods. People adhering to these eating patterns tend to have less incidence of CKD. What’s more, when individuals with CKD adopt these eating patterns, their disease progression often slows.

Plant Versus Animal Protein

The KDOQI guidelines and Academy’s Evidence Analysis Library support reduced protein consumption and close monitoring for adults with CKD stages 3 through 5 who are “metabolically stable” and not receiving dialysis. But while both state there is insufficient evidence to recommend one protein source over another — meaning animal versus plant protein — there may be reason to give this another look, since the guidelines are based upon the best information available as of April 2017 (or through August 2018 for any of the consensus opinion statements).

“While there was insufficient data to support a strong recommendation at that time, additional evidence favoring plant-based proteins has been published since,” says Annamarie Rodriguez, RDN, LD, FAND, who has been a nephrology dietitian for almost 25 years and has served on several boards of renal-related groups and held positions in Academy and affiliate groups. She works full time with an infusion company and runs a private practice.

Regardless, there is enough evidence to support the benefits of incorporating more plant foods and plant proteins for patients or clients with CKD or at risk for CKD, whether plant proteins are the basis of protein consumption or not.

Benefits of Plant Foods for CKD

Potential benefits of plant protein consumption and a plant-based diet for people with CKD may include decreased inflammation, less uremic toxins, reduced metabolic acidosis, improved gut microbiome from increased fiber intake and reduced bioavailability of certain nutrients such as phosphorus and potassium.

Inflammation

People with CKD are at higher risk of inflammation and inflammatory comorbid conditions. For instance, 40% of people with CKD also have Type 2 diabetes; 65% also have cardiovascular disease, and 50% to 75% have hypertension. Cardiovascular disease is the primary cause of death for people with CKD.

Diets higher in plant foods such as the Mediterranean, DASH and vegan and vegetarian diets have been associated with lower comorbidities and inflammation. A 2019 study found eating at least 800 grams of fruits and vegetables per day, or about five servings, showed heart-protective benefits. Furthermore, Rodriguez says there are dozens of epidemiological studies to suggest the protective and anti-inflammatory benefits of increased fruit and vegetable consumption.

“The phytochemicals and antioxidants in fruits and vegetables are so essential to what our patients need when we look at the comorbid conditions and inflammatory response mechanisms that are triggered with CKD,” Rodriguez says. “Eating an abundance of fruits and vegetables is the more natural way to combat that.”

Metabolic Acidosis

Metabolic acidosis, or the buildup of too many acids in the blood, can be both a contributor and a consequence of CKD, occurring because of the kidney’s reduced ability to filter and eliminate acids through urine. Too much acid in body fluids can lead to osteoporosis, insulin resistance and other endocrine disorders, muscle loss or protein energy wasting and worsening kidney disease.

Rodriguez explains that a diet high in animal protein favors acid production due to organic sulfur found in amino acids such as methionine and cysteine, which are oxidized to sulfate. “If we look at plant-based foods such as fruits, vegetables and legumes, they have natural alkaline precursors, such as citrate and malate, which are converted to serum bicarbonate that can act as a buffer.” While there are oral alkali medications, Rodriguez argues that eating a diet high in alkaline foods can be just as effective while providing the benefits of fiber, antioxidants and phytonutrients that are often lacking in the historic or traditional CKD diet.

Reviews in 2013 and 2015 both found a diet higher in fruits and vegetables is beneficial in treating and preventing metabolic acidosis. Randomized controlled trials published in 2012, 2013 and 2014 found eating more fruits and vegetables was as effective as oral sodium bicarbonate for people with CKD stages 2, 3 and 4 with metabolic acidosis.

Rodriguez says even if patients or clients aren’t ready to give up animal-based proteins, finding ways to incorporate more plant foods such as fruits and vegetables may help balance it out.

Bioavailability of Phosphorus and Potassium

Sweeping restrictions of foods high in phosphorus and potassium was once foundational to the CKD diet for people with CKD stages 3 through 5 and on dialysis. This generally resulted in people limiting their consumption of plant foods. However, research suggests the phosphorus and potassium in plant foods are less bioavailable, meaning the body does not absorb all the phosphorus and potassium present in plant sources. A 2018 study adds that animal proteins such as meat, poultry and fish can contain additives of phosphorus and potassium, in a more bioavailable form. The updated KDOQI guidelines suggest practitioners consider bioavailability of phosphorus sources.

“Any time I talk to dietitians about incorporating more plant-based proteins in patients with CKD, they’re more concerned about potassium and phosphorus,” Rodriguez says. She explains that the phosphorus in some plant foods comes in the form of phytic acid, which is largely indigestible in humans because they lack the enzyme phytase, which is needed to convert phytic acid into a more bioavailable form of phosphorus. She says the higher fiber in plant foods may help reduce absorption of both phosphorus and potassium. Additionally, newly introduced potassium binders can help patients and clients keep serum potassium levels within range while also eating more plant foods.

However, processing such as sprouting, fermenting and cooking can make phosphorus more bioavailable, which Rodriguez says she always discusses with her patients or clients. Rodriguez recommends registered dietitian nutritionists educate patients or clients on inorganic sources of phosphorus, which often are found in highly processed foods and beverages such as soda. Virtually all added (or inorganic) phosphorus is absorbed by the body.

RDN Takeaways

Despite the staggering amount of people who have CKD and the potential for medical nutrition therapy to slow the progression of the disease, only 10% of people with non-dialysis CKD are estimated to ever see an RDN. Barriers to MNT may include a lack of physician awareness and referrals, plus RDN availability. Whatever the cause, RDNs may want to consider advocating for the importance of nutrition for CKD whenever possible.

For some people, the cost of seeing a dietitian may be a reason they don’t receive or seek out medical nutrition therapy. To make appointments more affordable, RDNs in private practice could consider becoming Medicare providers, which cover a select number of appointments for beneficiaries with CKD who are not on dialysis or received a kidney transplant within the past 36 months and were referred by a physician.

Patients or clients may have preconceived notions or misconceptions that eating fruits, vegetables and whole grains will have a negative effect on their disease process. When counseling patients or clients, present the updated data and explain the benefits of eating more plant-based foods and create an individualized care plan. If patients or clients are not ready to make big changes, emphasize the impact of small, gradual shifts over time.

“Even small goals, even baby steps, can make a significant impact on health outcomes,” says Rodriguez. “Simple steps, such as swapping out one or two meals a week for a plant-based meal, can really add up.”

MORE TO LEARN

Watch these Academy webinars to take a deeper dive into the benefits of a plant-based diet for CKD and practical applications:

• The Emerging Benefits of a Plant-Forward Approach to the Chronic Kidney Disease Diet
• Plant-Forward with Chronic Kidney Disease
• Medical Nutrition Therapy for Chronic Kidney Disease Stages 1-5 Not on Dialysis
• Chronic Kidney Disease Nutrition Management Certificate of Training

References

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Ikizler TA, Burrowes JD, Byham-Gray LD, et al; KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020;76(3)(suppl 1):S1-S107.
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Wallace TC, Bailey RL, Blumberg JB, et al. Fruits, vegetables, and health: A comprehensive narrative, umbrella review of the science and recommendations for Enhanced Public Policy to improve intake. Crit Rev Sci Nutr 2019;60(13):2174-2211. doi:10.1080/10408398.2019.1632258
Metabolic Acidosis. National Kidney Foundation website. https://www.kidney.org/atoz/content/metabolic-acidosis. Accessed April 11, 2022.
Scialla JJ, Anderson CA. Dietary acid load: a novel nutritional target in chronic kidney disease?. Adv Chronic Kidney Dis. 2013;20(2), 141–149. https://doi.org/10.1053/j.ackd.2012.11.001
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Parpia AS, L’Abbé M, Goldstein M, Arcand J, Magnuson B, Darling PB. The Impact of Additives on the Phosphorus, Potassium, and Sodium Content of Commonly Consumed Meat, Poultry, and Fish Products Among Patients With Chronic Kidney Disease. J Ren Nutr. 2018;28(2):83-90. doi:10.1053/j.jrn.2017.08.013

Legumes, grains and nuts have qualities that naturally lend themselves to milky beverages. When cooked, legumes and grains both absorb water and become creamy. On Food and Cooking by Harold McGee explains that the fats in nuts and soybeans feel naturally creamy, not greasy, on the tongue.

Grains, legumes and nuts also have specific flavor compounds, which are sometimes detectible in plant-based drinks. McGee explains that the unsaturated fatty acids in legumes and nuts can have notes of floral or mushroom flavor, while the phenolic compounds in whole grains can have vanilla and toasted flavors.

Most plant-based beverages are marketed for use in cereal, smoothies, coffee and occasionally as an ingredient in baked goods and cooked savory dishes. Depending on the production method, some can separate when heated such as with soups. While this separation is not harmful, it may be undesirable, depending on the recipe.

Nutrition Overview

Plant-based milks do not have some components found in cow’s milk, including lactose and casein, which is helpful for those with a milk allergy or lactose intolerance. Dairy milk from cows is pasteurized and fortified with vitamins A and D, but beyond that, cow’s milk is one ingredient in its natural form.

Some plant-based drinks have fortification of nutrients at levels above those of dairy milk; amounts vary by brand, and some evidence suggests absorption may not be equal to that of cow’s milk. Unsweetened and fortified nondairy milks may be a choice if a child is allergic to cow’s milk, is lactose intolerant or does not eat dairy foods, but are otherwise not recommended as a full replacement for dairy milk. Like dairy milk, plant-based alternatives should not be used as infant formula or introduced to a child before age 1.

Additives

To turn a plant into a beverage, more processing is required, including cooking a grain or hydrating a seed, removing most fiber-rich solids, and in many cases adding additional protein, fat, preservatives, flavorings, thickeners, emulsifiers or other additives. As a result, the nutritional profile of plant-based drinks varies widely.

Foods such as barley, short-grain rice, oats and split peas become creamier, more gelatinous or thicker than others, such as quinoa. These hydrophilic plants “melt” into water. Still, to yield a mouthfeel similar to cow’s milk, several issues need to be resolved, including grittiness, sandiness, separation of solids and thin, watery consistency.

Soy and pea proteins: These are used to increase the protein content of drinks made from other plants, which are generally much lower in protein than dairy milk (except for soy, which is a complete protein). Soy and pea proteins can provide one of the creamiest textures compared to other plant proteins because they are some of the most soluble. Both also help emulsify beverages into a unified liquid because they hold water well. While these proteins solve many processing problems, they’re usually used in an isolate form, meaning they have been stripped of some minerals, fiber and healthy fats.

Calcium fortification: For added nutrition that’s closer to cow’s milk, calcium is often added in the form of calcium phosphate or calcium carbonate.

Potassium fortification: Dairy milk is a natural source of potassium, with about 390 milligrams per serving of 2% milk. Dipotassium phosphate and potassium citrate are buffering agents used to regulate pH, prevent coagulation and stabilize a drink; in “barista” beverages, these ingredients also can balance out the low pH of coffee so curdling doesn’t occur when added to a hot liquid. Fortification also results in higher potassium content, with some beverages having more than dairy.

Emulsifiers and thickeners: Commonly used to keep fat and water from separating and solids from settling on the bottom of beverage cartons, soy lecithin and sunflower lecithin are two examples of emulsifiers. Lecithin is a mixture of fatty acids naturally derived from plants (as well as animals) that attracts both water and fats. Chicory root fiber, pectin and native starches, such as tapioca starch, can give a drink a thicker mouthfeel. Locust bean gum and guar gum are derived from vegetables, whereas xanthan gum is obtained via microbial fermentation; all are used to create a thicker, more stable liquid. Seaweed and algae gums including agar-agar, alginic acid and carrageenan polysaccharides act as stabilizers and thickeners. Gellan gum, which can grow on aquatic plants but also is produced commercially through bacteria, is often used with fortified beverages to keep calcium suspended so it doesn’t sink to the bottom of the container.

Natural flavorings: These may include cinnamon and vanilla, for example, and often are proprietary. Therefore, the U.S. Food and Drug Association allows “natural flavors” to be listed in the ingredients list.

Added sugars: Most plant-based milks have a plain variety, which is generally free of added sugars. Some drinks taste especially sweet due to the natural flavors of the plant, such as barley and oats. Beverages with flavors such as vanilla, chocolate and even “original” may contain added sugars. Check the label for cane sugar and other sweetener ingredients or look at the amount of added sugars.

Plant-Based Beverages

Calcium-fortified soy: While milk-like drinks have been made from soybeans for centuries, commercial soy milks are produced using different processes than traditional Chinese and Japanese methods, which involved the use of natural enzymes to break down soybeans, yielding a milky product with a strong soy flavor.

With a similar nutrient profile to dairy, this is the only plant-based drink that is acceptable as a dairy alternative, according to the 2020-2025 Dietary Guidelines for Americans. Fortified soy milk also is the only plant milk that is recognized as an acceptable substitute for dairy milk in federal nutrition programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children.

The fatty acid profiles and types of proteins differ between dairy milk and soy drinks, but the total grams of protein are similar: 7 to 9 grams per serving. Soy beverage also has comparable levels of vitamins A and D, riboflavin and more vitamin B₁₂ due to fortification. Soy drinks are usually made with whole soy beans, not soy protein isolates, so they are included in the soy foods that may bear an authorized health claim in relation to their soy protein content and risk of coronary heart disease.

Soy beverages generally yield more comparable baked goods to those made with dairy milk, rather than items made with other plant drinks. Soy beverages can be used in cooked dishes, too, such as bread pudding, strata and custard, which is unusual for plant drinks.

Pea: A newer option on the market, it is made with yellow pea protein powder, which is easier to emulsify in a liquid than some other plants. Therefore, most manufacturers can use less emulsifiers and thickeners while still producing a thicker viscosity. The nutrition profile of some plain pea drinks is similar to soy beverages. One brand touts protein levels around 8 grams, 50% more calcium and half the carbohydrates of dairy milk. Some brands use fortification to provide DHA and up to 100% of the daily value for vitamin B₁₂ , which is important for vegetarians and vegans.

Results from baking and heating pea beverages are similar to those with soy drinks. Pea beverages also are very versatile in smoothies and baked goods. When heated or added to other hot drinks, some brands become even thicker.

Almond: The nutrient profiles of different brands of almond beverage vary greatly. A few brands use only almonds and water, yielding a very watery consistency but a short ingredient list. Other brands add emulsifiers, thickeners and ingredients such as oats for a blended drink. In general, most almond drinks are low in protein and carbohydrates and are fortified with minerals and vitamins including vitamin E, which is naturally found in almonds.

Almond milks can sometimes add a pleasantly nutty flavor to baked goods, but this flavor is often undetectable when drinking it. Baked items made with nut milks tend to brown quicker and have a more golden hue and squishier texture than those made with dairy milk. While it is not recommended to boil almond beverages, they can be heated into sauces or soups and a slightly sweet flavor may be present.

Rice: Some are made with partially milled or brown rice, which is preferable because more of the germ and bran of the whole grain remain. Per cup, rice drinks generally contain 1 gram of protein, 2 to 3 grams of fat (mainly from canola, sunflower or safflower oils) and most are fortified with calcium and vitamins A, D and B₁₂ at levels close to cow’s milk. The carbohydrate count is 13 to 23 grams, with about 13 grams of natural starch — higher than most plant-based milks. Products made from rice may be a source of arsenic, so it is recommended to consume a variety of foods to limit exposure, especially for young children.

In general, rice drinks are very thin and watery, a consistency that lends itself to smoothies and other liquid recipes. Because of the beverage’s high carbohydrate content, most baked recipes can be successful. The bland, blank-canvas flavor is helpful when making savory dishes, but it should be heated at lower temperatures for the best texture in soups.

Coconut: While both are made from grated coconut flesh, refrigerated varieties of coconut beverage are diluted with more water than canned coconut milk. The refrigerated type also may contain more additives to maintain a thicker texture without the same amount of saturated fat in the dense canned kind. Different refrigerated brands often have unique fortification amounts, including a high amount of vitamin B₁₂, which may be helpful for vegetarians and vegans. Coconut beverage is low in protein and carbohydrates, and many have about the same amount of total fat as 2% dairy milk but a higher amount of saturated fat.

Refrigerated coconut milk tends to have excellent frothing abilities and works well in smoothies and frothed warm drinks. Do not use it as a substitute for canned coconut milk in baked or stovetop recipes, since it is much lower in fat and the coconut flavor is less pronounced.

Sesame: Sesame beverage is rich in calcium, both naturally and through fortification (390 milligrams per 1-cup serving). One sesame drink maker uses sesame seeds after they are pressed for oil, upcycling a product previously considered food waste into a sesame protein concentrate. Other ingredients, such as pea protein, are added to increase the viscosity and protein (8 grams in regular and 4 grams in barista per 1 cup). Use the “barista” blend for frothy warm drinks and the regular version for baked goods to avoid altering the pH.

Oat: Because oat is a sweet grain that is naturally thick and gelatinous when hydrated, it produces a sweet and naturally thick drink. Surging in popularity, oat became the second best-selling plant-based drink in the United States in 2020, with almond as the top-selling plant drink and soy third.

The main ingredients are oats and water, with some additives and fortification. One manufacturer uses natural enzymes to break down the sugars in oats into maltose, creating a sweeter taste. The FDA considers these sugars “added,” since they were created during the production process.

In general, oat beverages have around 2 to 5 grams of fat, 16 to 19 grams of carbohydrates, 2 grams of fiber (with 1 gram soluble and some brands retaining the healthful beta glucans), 2 to 3 grams of protein and are fortified with calcium, potassium and vitamins A and B₁₂. Oat drinks perform well in baked goods and can produce a slightly sweet flavor when cooked.

Hemp: Hemp seeds are soaked until they swell and are then wet-milled and strained to produce this drink. Thickeners, emulsifiers, flavors and sweeteners are usually added. Because of their amino acid profile, hemp seeds are considered a source of high-quality protein. However, most hemp drinks contain only 2 to 3 grams of protein per serving. Hemp seeds also contain high amounts of omega-3 and omega-6 fats. While amounts vary between brands, some hemp beverages contain up to 3.5 grams per serving of these healthy fats. Unsweetened varieties contain no carbohydrates. Hemp beverages are best used in cool preparations, as cooking and baking can produce a strong flavor.

Pistachio: As of May 2022, the three most widely available pistachio drinks do not have any added oils. This is unusual as sunflower, rapeseed/canola, coconut and palm oils are generally added to help emulsify the solids, fats and liquid and give plant drinks a creamy texture. Therefore, most of the total fat listed on the Nutrition Facts label is from pure pistachio unsaturated fats. These drinks provide varying amounts of potassium due to natural potassium and dipotassium phosphate, which may be added to avoid curdling when added to hot coffee, for example. Even without oils, pistachio drinks froth up nicely and cook well, with baked goods having textures similar to those made with almond and cashew beverages.

Barley: There are two barley milk beverages on the market as of May 2022. One is made from spent beer brewing grains, previously a waste product that is upcycled. While most plant-based drink companies market their products for sustainability, this spent-grains process is unique (although somewhat similar to the production of sesame drink). In the process, sugars are extracted from malted barley and sent to fermentation for beer; what’s left is a protein-rich substrate called “brewer’s spent grain.” Using a special process, the spent grain is converted into a highly soluble protein to make barley beverage.

Nutrition profiles for plain and flavored varieties range from 3 to 8 grams of protein, 0 to 12 grams of added sugars and 70 to 140 calories; fortification provides 35% of the daily value for calcium and 25% to 50% of the daily value for vitamin D. Using barley beverage in recipes with cold and warm preparations works well.

Cashew: This is one of the only milk beverages that can be made without straining after solids are blended with water. Because the nut is softer, some companies produce drinks in which more of the whole nuts remain. Depending on fortification levels, some brands fortify calcium at levels above the 300 milligrams naturally found in 1 cup of dairy milk. Some cashew beverages separate when cooked on the stove top. Baked goods turn out similar to those made with other nut drinks.

Blended: A mix of several plant-based beverages and ingredients, these drinks have qualities not found in a single-origin beverage. For example, pairing a fruit flavor such as banana with sunflower seeds to increase protein and healthy fats, or adding oats for viscosity and pea protein for thickness and protein. With the substantial growth in plant-based milks, the blended category continues to produce innovative options.

References

2020-2025 Dietary Guidelines for Americans. https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf. Accessed April 22, 2022.
Almond Milk vs. Milk: Which Bakes the Best Muffin. Teaspoon Of Spice website. https://teaspoonofspice.com/almond-milk-muffins/. Accessed April 22, 2022.
Code of Federal Regulations Title 21. National Archives website. https://www.ecfr.gov/current/title-21/chapter-I/subchapter-B/part-101/subpart-E/section-101.82. Accessed May 24, 2022.
Gellan Gum. Bakerpedia website. https://bakerpedia.com/ingredients/gellan-gum/. Accessed April 22, 2022.
Healthy Beverage Consumption in Early Childhood. Healthy Drinks Healthy Kids website. https://healthydrinkshealthykids.org/app/uploads/2019/09/HER-HealthyBeverageTechnicalReport.pdf. Accessed April 30, 2022.
Hope and Sesame website. https://hopeandsesame.com/. Accessed April 22, 2022.
How We Make our Oat Drink. Oatly website. https://www.oatly.com/stuff-we-make/our-process. Accessed April 22, 2022.
How we upcycle. Take Two Foods website. https://taketwofoods.com/pages/how-we-upcycle. Accessed May 24, 2022.
McGee, H. On Food and Cooking: The Science and Lore of the Kitchen. New York, Scribner, 2004:459, 493-494.
Milk, 2% milkfat. Food Data Central website. https://fdc.nal.usda.gov/fdc-app.html#/food-details/746778/nutrients. Accessed May 24, 2022.
Oatmilk brands to update Nutrition Facts panels in light of FDA guidance on added sugar labeling. Food Navigator website. https://www.foodnavigator-usa.com/Article/2019/07/09/Oatmilk-brands-to-update-Nutrition-Facts-panels-in-light-of-FDA-guidance-on-added-sugar-labeling. Updated July 9, 2019. Accessed April 22, 2022.
Oatmilk edges past soy milk for #2 slot in US. Food Navigator website. https://www.foodnavigator-usa.com/Article/2020/09/25/Oatmilk-edges-past-soymilk-for-2-slot-in-US-plant-based-milk-retail-market-as-almondmilk-continues-to-drive-category-sales. Accessed April 22, 2022.
Original Plant Based Milk. Ripple Foods website. https://www.ripplefoods.com/original-plant-milk/. Accessed April 22, 2022.
Overview of Food Ingredients: Types of Food Ingredients. Food and Drug Administration website.  https://www.fda.gov/food/food-ingredients-packaging/overview-food-ingredients-additives-colors#types. April 30, 2022.
Plant Proteins Come of Age. Institute of Plant Technologists website. https://www.ift.org/news-and-publications/food-technology-magazine/issues/2021/march/columns/ingredients-plant-proteins-come-of-age. Accessed April 22, 2022.
Plant-Based Milks: Almond. IFAS Extension University of Florida website. https://edis.ifas.ufl.edu/publication/FS410. Accessed April 22, 2022.
Plant-Based Milks: Cashew. IFAS Extension University of Florida website. https://edis.ifas.ufl.edu/publication/FS413. Accessed April 22, 2022.
Plant-Based Milks: Coconut. IFAS Extension University of Florida website. https://edis.ifas.ufl.edu/publication/FS411. Accessed April 22, 2022.
Plant-Based Milks: Hemp. IFAS Extension University of Florida website. https://edis.ifas.ufl.edu/publication/FS420. Accessed April 22, 2022.
Plant-Based Milks: Oat. IFAS Extension University of Florida website. https://edis.ifas.ufl.edu/publication/FS419. Accessed April 22, 2022.
Plant-Based Milks: Rice. IFAS Extension University of Florida website. https://edis.ifas.ufl.edu/publication/FS412. Accessed April 22, 2022.
Plant-Based Milks: Soy. IFAS Extension University of Florida website. https://edis.ifas.ufl.edu/publication/FS422. Accessed April 22, 2022.
What are the Uses of Potassium Citrate? Food Additives website. https://foodadditives.net/acidity-regulator/potassium-citrate/. Accessed April 22, 2022.
What is a Natural Flavor? Elmhurst website. https://elmhurst1925.com/blogs/news/natural-flavors-elmhurst-explains. Accessed April 22, 2022.
What is Dipotassium Phosphate in Food and Fertilizer? Food Additives website. https://foodadditives.net/phosphates/dipotassium-phosphate/. Accessed April 22, 2022.
What is the difference between the barista edition and regular oat drinks? Oatly website. https://www.oatly.com/random-answers. Accessed April 22, 2022.
What You Can Do to Limit Exposure to Arsenic. Federal Drug Administration website. https://www.fda.gov/food/metals-and-your-food/what-you-can-do-limit-exposure-arsenic. Accessed May 24, 2022.

Lupini beans originated in the Middle East and date back before Ancient Rome. Today, they are commonly associated with Italian cuisine and are also enjoyed in Greece, Spain and Portugal. Lupini beans are served as street food in countries such as Jordan and Egypt, too.

A ½-cup serving of cooked lupini beans contains about 100 calories, 13 grams of protein and 2 grams of dietary fiber and is a good source of zinc and magnesium. A higher protein content and increased interest in plant-based proteins may be to thank for their recent rise in popularity in the United States.

Dried or canned lupini beans are sold in many large supermarkets. Smaller Italian, Middle Eastern, Spanish and Portuguese food stores offer them brined or pickled in a jar. The beans also may be used as flours in baked goods; according to the Food and Drug Administration, some people, especially those allergic to peanuts, may have allergic reactions to products made with lupini.

Dried bitter lupini beans should soak for several days. The “sweet” variety need to soak only for a few hours. Cook per package instructions. Lupini beans have thick skins, which are edible but are often removed before eating.

A traditional Italian Christmas holiday dish combines lupini beans with green or black olives. You also can add lupini beans to salads for extra protein or eat them as a side dish.

References

Canned Lupini Beans 25.4 oz. Delallo website. https://www.delallo.com/delallo-imported-lupini-beans-25-4oz/. Accessed February 9, 2022.
Lupin Beans. USDA Food Data Central website.
Lupini Beans. Little Sunny Kitchen website. https://littlesunnykitchen.com/lupini-beans/. Updated January 4, 2022. Accessed February 9, 2022.
Lupini Beans. Precision Nutrition website. https://www.precisionnutrition.com/encyclopedia/food/lupini-beans#:~:text=Nutrition%20Info,phosphorus%2C%20potassium%2C%20and%20zinc. Accessed February 9, 2022.
The Lupini Bean Legend. Arthur Avenue Food Tours website. https://arthuravenuefoodtours.com/what-to-buy-on-arthur-avenue-bronx-little-italy/2017/4/lupini-beans. Published April 22, 2017. Accessed February 9, 2022.
What Are Lupin Beans? Meet The Superfood Transforming Vegan Food, From Milk to Meat. Green queen website. https://www.greenqueen.com.hk/what-are-lupin-beans/. Published July 29, 2021.
What are lupini beans? Chicago Tribune website. https://www.chicagotribune.com/lifestyles/ct-tribu-daley-question-lupini-beans-20110621-story.html. Published June 21, 2011. Accessed February 9, 2022.

The climatarian diet focuses heavily on reducing environmental impact through reducing intake of animal products and opting for a more plant-based eating pattern. It promotes veganism, vegetarianism and pescatarianism as more sustainable ways of eating.

For people who eat animal products, the climatarian diet encourages choosing pork, poultry, sustainable fish such as blue crab, dairy products and eggs over beef, lamb, goat and unsustainable fish such as swordfish, which are commonly overfished, as a means to reduce food emissions. According to Harvard’s T.H. Chan School of Public Health, beef accounts for 36% of greenhouse gas emissions in the United States and producing one pound of lamb creates five times more greenhouse gas emissions than producing a pound of chicken.

In addition to choosing more plant-based foods, proponents of the climatarian diet urge people to eat locally grown and seasonal fruits and vegetables. Other food-related methods of reducing environmental impact promoted by the climatarian diet are avoiding air-flown food, food grown in heated greenhouses, highly packaged foods or disposables and limiting food waste. Composting is suggested.

In summary, the climatarian diet is not a strict set of rules or “forbidden” foods but more of an appeal by members of a global social network for people to consider the environmental impact of their food choices and adjust wherever possible.

References

10 Types of Seafood You Really Shouldn’t Eat (and 10 You Should). Thrillist website. https://www.thrillist.com/eat/nation/the-least-sustainable-seafood-fish-you-shouldn-t-eat. Published June 15, 2015. Accessed February 11, 2022.
Eating Climatarian. Climatarian website. https://climatarian.com/. Accessed February 9, 2022.
The Climatarian Diet. Climatarian website. https://climatarian.com/. Accessed February 9, 2022.
The Nutrition Source: Protein. Harvard T.H. Chan School of Public Health website. https://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/protein/#ref2. Accessed February 9, 2022.

Prior to the COVID-19 pandemic, the global population was considered “healthier” than previous years, based on metrics including increased life expectancy, decreased child mortality and decreased global poverty levels. This “healthier” status was acknowledged by the Rockefeller Foundation-Lancet Commission on Planetary Health to be a direct result of increased use — and, in some cases, misuse — of resources such as energy and water use, deforestation and carbon dioxide emissions. While the impact of COVID-19 on this “healthier population” status is still largely unknown, a report from the Population Reference Bureau in August 2021 found that the current trajectory indicates a global population of 9.7 billion by 2050, a nearly 24% increase over 2020.

The growing population will put a greater strain on the ecosystem and resources, further contributing to climate change, which is observed through increased temperatures, rising sea levels and severe weather patterns. These factors impact human health, both directly and indirectly. “We can no longer separate the health of the environment from the health of humans. It is all interconnected,” says Mary Purdy, MS, RDN, an integrative eco-dietitian and adjunct faculty lecturer at Bastyr University.

Impact of Climate Change on Human Health and Nutrition
Altered weather patterns directly affect yields and crop production, which along with non-climate factors, can impact the four pillars of food security: availability, access, utilization and stability. Displacement from homes, decreased access to resources such as health care and illness due to exposure to extreme temperatures can have long-term health consequences.

For example, the extreme drought in Ethiopia in 2016 caused widespread crop failure and resulted in nearly 10 million people requiring food aid. Similarly, in the U.S., 2021 brought Hurricane Ida to the Gulf Coast, killing an estimated 91 people. When the storm subsided, extreme heat followed, which was particularly dangerous given many had lost their homes or electricity in the hurricane. Widespread power outages left people with limited access to essentials including groceries, clean water and, in some instances, home health devices such as at-home dialysis.

The challenge of feeding more people using the current food systems poses a threat to biodiversity. For example, overfishing, which involves non-sustainable practices that deplete or endanger species, can result in biodiversity loss. Conversely, “the more variety of crops grown in one farming system, the more resilient that system is,” Purdy says. “The less biodiversity you have in an ecosystem, the more susceptible it is to pests, crop failure and soil degradation, including the soil microbiome; as we know, there is a significant connection between the soil microbiome and human gut microbiome.”

As more ecosystems and species become threatened, biodiversity will continue to decrease, which will impact the entire food chain. Each organism and species plays a role in the food chain; altering that chain will have a domino effect, which could impact human health in numerous ways, such as altering typical eating habits based on availability and in some cases resulting in nutrition insecurity, reducing gut microbiome and impacting the availability of some medicinal resources.

Inequities of Climate Change
Climate change cannot be addressed in isolation — environmental justice must be part of the conversation. Environmental justice addresses how climate change disproportionately impacts groups and communities in underdeveloped and low-income regions. According to Greenpeace, environmental justice “acknowledges how privilege, power and oppression are integral to our understanding of how we are impacted by climate change and our environment.”

A recent report from the U.S. Environmental Protection Agency evaluated the degree to which socially vulnerable populations are exposed to different effects of climate change and found that racial and ethnic minorities are at greater risk of exposure. “Hispanic and Latino individuals are 43% more likely to currently reside in areas with the highest projected reductions in labor hours due to extreme temperatures,” the report states, which could have a negative effect on livelihood and overall well-being. In this instance, many people who help grow and produce food are at the greatest risk for negative implications from climate change.

Role of Food Systems in Climate Change
While greenhouse gas emissions are hard to quantify, the understanding that food systems contribute a significant portion of total global emissions is widely accepted. One study from 2015 estimated that food systems (production, processing, transportation, packaging, consumption and disposal) were responsible for about one-third of global carbon emissions, at 18 gigatons of carbon dioxide equivalent per year globally. That’s the equivalent of emissions from more than 3.5 billion passenger vehicles in a year. Another recent study indicates that production of animal-based foods accounts for about twice the amount of greenhouse gas emissions of plant-based foods.

Alternatively, alterations in temperature or weather patterns can impact crop growing cycles. Natural disasters such as droughts and floods can cause interruptions and sometimes destruction of crops and farming practices.

Sustainable and Equitable Policy Reform
Legislation such as the Farm Bill, which is updated every five years, is one tool the U.S. is using to help support evolving food systems. The Farm Bill addresses agriculture and food programs including the Supplemental Nutrition Assistance Program and crop insurance for farmers.

Sustainability is a global problem and requires a global solution. The Paris Climate Agreement, adopted by 193 countries as of February 2022, is an international action plan to fight climate change and its negative impacts through a reduction in greenhouse gas emissions and slow the rate of global temperature increase to 1.5 degrees Celsius by 2050. However, a recent report indicates that without immediate and large-scale changes, it may already be too late to achieve this goal.

In November 2021, global leaders at the United Nations’ COP26 Climate Change Conference discussed progress toward the Paris Agreement’s framework and negotiated commitments and partnerships. The conference came on the heels of the UN Food Systems Summit, which focused on necessary transformation of food systems specifically to achieve the UN’s 17 Sustainable Development Goals by 2030. The goals are a framework to address health, inequality, economics and sustainability. Commitments at the summit included 150 organizations agreeing to green agriculture innovation and 45 nations promising policy reform.

Future of Food Systems
As a direct result of the current stress on food systems, new innovative techniques and resources are arising, such as heat-resistant seeds, procurement and production methods that use fewer natural resources; developing cell-based meat; regenerative agriculture solutions that draw carbon out of the atmosphere to achieve net-zero emissions and more. Experts recommend following the lead of indigenous people, who manage a quarter of the Earth’s surface and preserve most of the remaining biodiversity.

We also can expect recommendations for food consumption to shift toward eating patterns that balance health and sustainability. Addressing this topic, the EAT-Lancet Report published in 2019 was the first full scientific review and recommendation for a healthy diet from a sustainable food system to support a future population of 10 billion people. However, these new approaches are not foolproof. The EAT-Lancet Report received criticism about assumptions and methods used to demonstrate noncommunicable
disease mortality rates, the affordability of the diet and the impact a global implementation could have on people’s health and livelihoods, since the diet promotes a primarily plant-based eating pattern.

Individual Advocacy and Action
Registered dietitian nutritionists are uniquely positioned to advocate for a more sustainable and equitable future. Those working in foodservice may think creatively about reducing food waste and packaging. Those in community settings can help people and communities grow and prepare their own food. Those in clinical and counseling settings may recommend ways for people to incorporate more plant-based options. Those in media and communications can use their platforms for strategic storytelling about human and planetary health.

“From planting that seed in the ground to how we grow and harvest the food or raise and slaughter the animal, to how we transport, store, distribute, process, package, prepare, consume and dispose of it — all of those parts of the food system have an impact on the environment, which have an impact on human health,” Mary Purdy says. “We can help dictate how all these processes occur to benefit both people and the planet.”

The Academy and its Foundation offer resources including the Future of Food Initiative; the Hunger and Environmental Nutrition dietetic practice group; the Food and Culinary Professionals DPG’s agriculture subgroup; Food System Sustainability: An Academy Advocacy Priority; Cultivating Sustainable, Resilient, and Healthy Food and Water Systems: A Nutrition-Focused Framework for Action; and the Revised 2020 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient and Expert) in Sustainable, Resilient and Healthy Food and Water Systems. Purdy also recommends Food and Planet, a dietitian-run organization, Planetary Health Collective and Johns Hopkins free Coursera courses on sustainable diets.

In addition to food waste reduction, people can advocate for a more sustainable and equitable future with their purchasing power. Buying from companies that have sustainable practices and commitments in place and shopping locally and seasonally can be great ways to make a difference. While these actions may seem small, if done at scale, they could largely affect overall greenhouse gas emissions and climate change, helping to protect both humans and the planet for years to come.

References

Adoption of the Paris Climate Agreement. United Nations. https://s3.documentcloud.org/documents/2646274/Updated-l09r01.pdf. Published December 12, 2015. Accessed January 12, 2022.
Agriculture and Climate. EPA website. https://www.epa.gov/agriculture/agriculture-and-climate. Accessed January 24, 2022
Climate Change – Widespread, Rapid, and Intensifying – IPCC. IPCC website. https://www.ipcc.ch/2021/08/09/ar6-wg1-20210809-pr/ Published August 9, 2021. Accessed January 11, 2022.
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Environmental Justice. Greenpeace website. https://www.greenpeace.org/usa/issues/environmental-justice/. Accessed January 12, 2022.
EPA Report Shows Disproportionate Impacts of Climate Change on Socially Vulnerable Populations in the United States. EPA website. https://www.epa.gov/newsreleases/epa-report-shows-disproportionate-impacts-climate-change-socially-vulnerable#:~:text=2%2C%202021)%20%E2%80%94%20A%20new,%2C%20flooding%2C%20and%20other%20impacts Published September 2, 2021. Accessed January 27, 2022.
Food Security and Sustainability. Academy of Nutrition and Dietetics website. https://www.eatrightpro.org/practice/practice-resources/food-security-and-sustainability Accessed January 25, 2022.
Future Farm Bills: Is It Time to Advocate Beyond Nutrition? FNCE 2019 webinar. eatrightSTORE website. https://www.eatrightstore.org/collections/fnce-2019/144-future-farm-bills-is-it-time-to-advocate-beyond-nutrition Released October 29, 2019. Accessed January 30, 2022.
Greenhouse Gas Equivalencies Calculator. EPA website. https://www.epa.gov/energy/greenhouse-gas-equivalencies-calculator. Accessed January 28, 2022.
Hirvonen K, Bai Y, Headey D, Masters WA. Affordability of the EAT-Lancet reference diet: a global analysis. Lancet Glob Health. 2020 Jan;8(1):e59-e66. doi: 10.1016/S2214-109X(19)30447-4.
How Does Overfishing Affect Biodiversity? Let’s Do a Deep Dive. Green Matters website. https://www.greenmatters.com/p/how-overfishing-affects-biodiversity. Published December 29, 2020. Accessed January 24, 2022.
How Much Are Our Food Systems Responsible for Climate Change? World Economic Forum website. https://www.weforum.org/agenda/2021/04/study-food-systems-drive-an-estimated-one-third-of-greenhouse-gas-emissions. Accessed January 13, 2022
New Orleans Begins Evacuating Residents Amid Outages As Power Could Come Back On In Coming Days. The Washington Post website. https://www.washingtonpost.com/national/new-orleans-begins-evacuating-residents-amid-outages-as-power-could-come-back-on-in-coming-days/2021/09/03/b607c700-0d07-11ec-a6dd-296ba7fb2dce_story.html. Published September 3, 2021. Accessed January 24, 2022.
Notes from the Field: Deaths Related to Hurricane Ida Reported by Media – Nine States, August 29 – September 9, 2021. CDC website. https://www.cdc.gov/mmwr/volumes/70/wr/mm7039a3.htm. Published October 1, 2021. Accessed January 24, 2022.
Paris Climate Agreement: Everything You Need to Know. NRDC website. https://www.nrdc.org/stories/paris-climate-agreement-everything-you-need-know. Published February 19, 2021. Accessed January 13, 2022.
Safeguarding human health in the Anthropocene epoch; report of the Rockefeller Foundation — Lancet Commission on planetary health. The Lancet Commissions. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60901-1/fulltext. Accessed January 11, 2022.
Special Report on Climate Change and Land. IPCC website. https://www.ipcc.ch/srccl/chapter/chapter-5/. Accessed January 11, 2022
Sustainable Development. United Nations website.
Top Food Trends for 2022. U.S. News website. https://health.usnews.com/health-news/blogs/eat-run/slideshows/top-food-trends-for-2022. Published December 21, 2021. Accessed January 25, 2022.
Torjesen I. WHO pulls support from initiative promoting global move to plant based foods. BMJ. 2019;365:l1700. doi:10.1136/bmj.l1700
USDA Invests $50 Million in Partnerships to Improve Equity in Conservation Programs, Address Climate Change. USDA website. https://www.nrcs.usda.gov/wps/portal/nrcs/detail/national/newsroom/releases/?cid=NRCSEPRD1868022. Published January 10, 2022. Accessed January 24, 2022.
USDA Offers Expanded Conservation Program Opportunities to Support Climate Smart Agriculture in 2022. USDA website. https://www.usda.gov/media/press-releases/2022/01/10/usda-offers-expanded-conservation-program-opportunities-support. Published January 10, 2022. Accessed January 24, 2022.
What is Planetary Health? Forbes website. https://www.forbes.com/sites/johndrake/2021/04/22/what-is-planetary-health/?sh=21914fc22998. Published April 22, 2021. Accessed January 11, 2022.
Xu X, Sharma P, Shu S. (2021). Global greenhouse gas emissions from animal-based foods are twice those of plant-based foods. Nature Food. 2021;2,724-732. https://doi.org/10.1038/s43016-021-00358-x.
Zagmutt FJ, Pouzou JG, Costard S. (2020). The EAT-Lancet Commission’s Dietary Composition May Not Prevent Noncommunicable Disease Mortality. J Nutr. 2020;150(5), 985–988. https://doi.org/10.1093/jn/nxaa020.

Signs and Symptoms
Common symptoms include pain, swelling or stiffness in more than one joint, usually on both sides of the body. Stiffness is typically worse in the morning, getting better as the day progresses. Joints most impacted by rheumatoid arthritis are in the hands, wrists and knees, but other joints and organs such as the lungs, heart and eyes can be affected. Other symptoms may include weight loss, fever, weakness or fatigue.

It is common for people with RA to experience flares — times when symptoms get worse — and remission, when symptoms improve.

Risk Factors
The cause of rheumatoid arthritis is unknown. Factors that may increase risk of development include aging and genetics. According to the American College of Rheumatology, about 75% of people diagnosed with RA are women. Additional risk factors include smoking, obesity, early life exposures such as children whose mothers smoked and social determinants of health. Conversely, breastfeeding has been found to decrease risk.

Diagnosis
Blood tests are one of many completed to determine if a person has rheumatoid arthritis and are an important factor in determining whether a person has seropositive or seronegative RA. Seropositive is the most common form; it means the person has antibodies called anti-cyclic citrullinated peptides or rheumatoid factors. These antibodies attack joints and cause inflammation. Usually, people with seropositive RA will experience more severe symptoms.

Nutrition for Prevention
Though evidence is limited, some research suggests diet may play a role in the prevention of rheumatoid arthritis. Using data from two cohort studies of nearly 170,000 women, researchers found a healthier overall dietary pattern (measured by the 2010 Alternative Healthy Eating Index) led to reduced risk in women 55 or younger. In this age-specific analysis of the study, women with the highest healthy eating index scores, indicating an overall healthier diet, showed a 33% reduction in RA risk compared to those with the lowest scores.

Authors of a 2018 review discussed the potential of the Mediterranean diet for prevention. Noting the prevalence of rheumatoid arthritis in Southern Europe is lower than Northern Europe and the United States, they argued the Mediterranean diet could be a factor since it is higher in antioxidants, unsaturated fats and foods with anti-inflammatory properties compared to the typical Western diet; however, more evidence is needed.

Other studies hint that reducing sodium and sugar-sweetened soda intake may reduce risk. A cross-sectional study of 18,555 people found high sodium consumption (an average of nearly 5,000 milligrams a day) was associated with self-reported rheumatoid arthritis, while a case-control study found a significant association only existed between high sodium consumption and risk for RA among smokers, and it was dose dependent, more than doubling their risk. Additionally, another study found women who drank one or more servings of sugar-sweetened soda a day may be at an increased risk of seropositive RA (but not seronegative).

Nutrition for Disease Management
Researchers are equally interested in the Mediterranean diet for rheumatoid arthritis management but, so far, findings are mixed. Results of a 2018 systematic review showed two prospective studies found no significant benefits of following a Mediterranean diet, while two clinical trials reported modest but favorable outcomes. One clinical trial reported improvement in pain and physical function after three months and reduced stiffness after six months following the Mediterranean diet. Participants in the other clinical trial saw swelling and inflammatory biomarker improvements after three months.

Of studies included in a 2020 systematic review on the effects of diet and dietary supplements on Disease Activity Score in 28 joints, or DAS28 which measures rheumatoid arthritis severity, one reported a significant improvement after 12 weeks of following the Mediterranean diet, while another reported benefits after 10 weeks, but those results were not statistically significant.

Supplements
The same systematic review looked at three small studies of various spices (administered in high doses in capsules or tablets) on DAS28. One study had participants supplement with 1.5 grams of ginger powder daily for three months; another with 2 grams of cinnamon (Cinnamomum burmannii) powder daily for two months; and another with 100 milligrams of saffron daily for three months. All three studies reported significant improvement in DAS28 when compared to placebo.

Similar results were shown in a pilot study on curcumin. Participants who supplemented 500 milligrams twice daily for eight weeks had the highest improvement in overall DAS28 scores compared to participants who supplemented with 50 milligrams diclofenac sodium (a pain medication) alone or in combination with curcumin.

Omega-3 Fatty Acids
Evidence of supplemental omega-3 fatty acid intake on RA symptoms is limited and inconsistent. Some research suggests it may help reduce the number of swollen and tender joints, and some studies suggest omega-3 fatty acid supplements may reduce the need for medication. For example, when supplementing with 10 grams of fish oil daily (containing 1.8 grams of EPA and 1.2 grams of DHA), one study found a decreased need for non-steroidal anti-inflammatory drugs.

Probiotics
A 2020 systematic review found two studies that supported benefits of supplementing with probiotics containing L. casei. One study had participants supplement with a capsule of L. casei 01 (10⁸ colony forming units) and maltodextrin daily for two months, which resulted in a lower inflammatory marker score for the intervention group compared to those who only took maltodextrin. The other had participants take capsules containing L. casei (2 × 10⁹ colony forming units), L. Acidophilus (2 × 10⁹ colony forming units) and B. Bifidum (2 × 10⁹ colony forming units) daily for two months. Among the beneficial effects reported in this randomized, double-blind, placebo-controlled trial was an improvement in DAS28 compared to placebo.

Lifestyle
The Centers for Disease Control and Prevention recommend adults with arthritis aim for at least 150 minutes of moderate physical activity each week. Research has shown physical activity can help manage pain from rheumatoid arthritis and improve quality of life for people with RA. However, for someone experiencing a flare, the American College of Rheumatology recommends prioritizing rest and opting for gentle range-of-motion exercises, such as stretching.

Several community-based, physical activity programs are recommended by the CDC; they have been proven to reduce symptoms and help participants safely increase their physical activity.

Epidemiological studies suggest smoking significantly increases risk and complications of rheumatoid arthritis; recommend to clients and patients that they quit.

RDN Takeaways
Until data is more conclusive concerning the effects of diet and dietary supplements on RA prevention and symptom management, registered dietitian nutritionists should encourage patients and clients to follow an overall balanced and healthful eating pattern consistent with the 2020-2025 Dietary Guidelines for Americans. Emphasize limiting sodium consumption and encourage patients and clients to eat foods higher in unsaturated fats and dietary fiber, as well as a variety of fruits and vegetables, whole grains, lean protein foods (especially fatty fish) and low-fat or fat-free dairy.

People with rheumatoid arthritis are at risk for malnutrition, so RDNs need to tailor nutrition interventions to address disease severity, polypharmacy and comorbidities. Referrals for occupational or physical therapy may need to be considered. Finally, educate patients and clients on the benefits of appropriate physical activity for RA management and help them find healthful ways to incorporate more movement into their daily lives.

References

Academy of Nutrition and Dietetics. Nutrition Care Manual. Rheumatoid Arthritis. https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=272978&lv2=30456&ncm_toc_id=30456&ncm_heading=Nutrition%20Care. Accessed February 10, 2022
Arthritis: Key Public Health Messages. Centers for Disease Control and Prevention website. https://www.cdc.gov/arthritis/about/key-messages.htm. Reviewed August 26, 2021. Accessed January 28, 2022.
Chandran B, Goel A. A randomized, pilot study to assess the efficacy and safety of curcumin in patients with active rheumatoid arthritis. Phytother Res. 2012;26(11):1719-1725.
Chang K, Yang SM, Kim SH, Han KH, Park SJ, Shin JI. Smoking and rheumatoid arthritis. Int J Mol Sci. 2014;15(12):22279-22295. Published 2014 Dec 3. doi:10.3390/ijms151222279.
Di Giuseppe D, Wallin A, Bottai M, Askling J, Wolk A. Long-term intake of dietary long-chain n-3 polyunsaturated fatty acids and risk of rheumatoid arthritis: a prospective cohort study of women. Ann Rheum Dis. 2014;73(11):1949-1953.
Disease Activity Score (DAS)/Disease Activity Score in 28 joints (DAS28). American College of Rheumatology website. https://www.rheumatology.org/Learning-Center/Glossary/ID/451/. Accessed January 25, 2022.
Forsyth C, Kouvari M, D’Cunha NM, et al. The effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment: a systematic review of human prospective studies. Rheumatol Int. 38, 737–747 (2018).
Forsyth C, Kouvari M, D’Cunha NM, et al. The effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment: a systematic review of human prospective studies. Rheumatol Int. 38, 737–747 (2018).
Hu Y, Costenbader KH, Gao X, et al. Sugar-sweetened soda consumption and risk of developing rheumatoid arthritis in women. Am J Clin Nutr. 2014;100(3):959-967. doi:10.3945/ajcn.114.086918.
Hu Y, Sparks JA, Malspeis S, et al. Long-term dietary quality and risk of developing rheumatoid arthritis in women. Ann Rheum Dis. 2017;76(8):1357-1364.
Kostoglou-Athanassiou I, Athanassiou L, Athanassiou P. The Effect of Omega-3 Fatty Acids on Rheumatoid Arthritis. Mediterr J Rheumatol. 2020;31(2):190-194. Published June 30, 2020.
Nelson J, Sjöblom H, Gjertsson I, Ulven SM, Lindqvist HM, Bärebring L. Do Interventions with Diet or Dietary Supplements Reduce the Disease Activity Score in Rheumatoid Arthritis? A Systematic Review of Randomized Controlled Trials. Nutrients. 2020;12(10):2991. Published September 29, 2020.
Omega-3 Fatty Acids. National Institutes of Health Office of Dietary Supplements website. https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/#rheumatoid. Updated August 4, 2021. Accessed February 8, 2022.
Pedersen M, Stripp C, Klarlund M, Olsen SF, Tjønneland AM, Frisch M. Diet and risk of rheumatoid arthritis in a prospective cohort. J Rheumatol. 2005;32(7):1249-1252.
Physical Activity Programs. Centers for Disease Control and Prevention website. https://www.cdc.gov/arthritis/interventions/physical-activity.html. Reviewed April 16, 2021. Accessed January 28, 2022.
Rheumatoid Arthritis (RA). Centers for Disease Control and Prevention website. https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html. Reviewed July 27, 2020. Accessed January 18, 2022.
Rheumatoid Arthritis Also called: RA. MedlinePlus website. https://medlineplus.gov/rheumatoidarthritis.html. Accessed January 18, 2022.
Rheumatoid Arthritis. American College of Rheumatology website. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis. Updated March 2019. Accessed January 18, 2022.
Salgado E, Bes-Rastrollo M, de Irala J, Carmona L, Gómez-Reino JJ. High Sodium Intake Is Associated With Self-Reported Rheumatoid Arthritis: A Cross Sectional and Case Control Analysis Within the SUN Cohort. Medicine (Baltimore). 2015;94(37):e0924.
Seropositive and seronegative. National Rheumatoid Arthritis Society website. https://nras.org.uk/resource/seropositive-and-seronegative/. Updated February 4, 2019. Accessed February 8, 2022.
Seropositive Rheumatoid Arthritis. Healthline website. https://www.healthline.com/health/seropositive-rheumatoid-arthritis. Updated January 26, 2021. Accessed February 8, 2022.
Sundström B, Johansson I, Rantapää-Dahlqvist S. Interaction between dietary sodium and smoking increases the risk for rheumatoid arthritis: results from a nested case-control study. Rheumatology (Oxford). 2015;54(3):487-493.
What Type of RA Do You Have? WebMD website. https://www.webmd.com/rheumatoid-arthritis/rheumatoid-arthritis-types. Reviewed October 19, 2021. Accessed February 8, 2022.

Open science includes multiple principles: for publications (open access), data sets (open data) and software/application code (open source). Other examples include open-source models for sharing intellectual property and open governance practices. While the application and interpretation of the principles of open science can vary across platforms and countries (for example, whether single articles or entire journals are open access) the goals are the same: to bring research results to the surface and to improve transparency by making information available to the most people as efficiently as possible.

Open access journals
Open access journals offer full access to articles with no fees to the end-user. They are primarily published online and anyone — from the public to a clinician, program manager or policymaker — can easily access the published work. As of December 2021, there were 17,214 open access journals from 130 countries listed in the Directory of Open Access Journals. All open access journals listed in the DOAJ must follow the “Principles of transparency and best practice in scholarly publishing,” a set of standards and best practices created by the DOAJ, Committee on Publication Ethics, Open Access Scholarly Publishers Association and World Association of Medical Editors. And just like traditional publications, many open access journals follow rigorous peer-reviewed processes for article solicitation and selection.

There are supports in place for journal publishers and funding bodies to guide the transition from traditional to open access publishing. In 2018, cOAlition S, an international group of research organizations, published its Plan S principles to help move the needle on open access publishing. Organizations that agree to implement the principles commit to transition to open access within one year of the agreement.

While readers have no fees to pay, open access journals may still have article processing charges, or APCs. These fees are paid by the author or a funding body for the article to be published as open access. Waivers can be obtained for APCs in some situations. It’s worth taking time to research the fee waiver process, because these fees can amount to thousands of dollars, depending on the journal. Even if the entire publication isn’t fully open access (known as Gold Open Access), an author can pay for an open access license in a hybrid journal (a mix of open access and subscription) for the article they have written. Again, the APC can be cost-prohibitive, but an author, author’s organization or a funding body may be willing to pay the APC so the published work can be more widely shared.

There are different types of licenses for content in terms of requirements for attribution and any restrictions such as limitations on commercial use, so it is important to check any publisher or funding entity requirements related to licensing. Many open access licenses fall under Creative Commons; learn more about these licenses here. In addition, if the research received outside funding, the funder may require any resulting publications be open access. The Bill & Melinda Gates Foundation, for example, has had an open access policy in place since 2015 for its funding recipients and awardees. Under this policy, “all peer-reviewed published research funded, in whole or in part, by the foundation, including any underlying data sets” must have unrestricted access. Finally, federally funded research, such as by the National Institutes of Health, is made publicly available through PubMed Central as part of NIH’s Public Access Policy.

Open data
Open data involves the placement of data sets in publicly accessible online locations for download or the unlimited provision of datasets via electronic file delivery by direct request. Open data is not new, particularly when it comes to the government. Since 2009, there have been government policies for open data. According to the World Bank’s Open Data Toolkit, more than 250 governments and 50 countries have open data initiatives. The Open, Public, Electronic and Necessary Government Data Act of 2018 expanded the open data policy for the U.S. federal government and requires agencies to “publish information as open data by default, as well as develop and maintain comprehensive data inventories.” There also are global and national open data repositories, such as World Bank Open Data, UNData (United Nations), GODAN (Global Open Data for Agriculture and Nutrition) and Data.gov, the U.S. Government Open Data Portal.

The more data that’s made available, the more opportunities for secondary analysis; consolidation of smaller data sets into big data that can be mined for patterns and learnings; and future research projects that take what has been done to the next level. This can mean a bigger patient pool, a larger demonstration project, a revamped intervention approach and more.

Any data collected as part of surveys, electronic health records or other forms or processes can be made “open” as well, depending on the policies in place and the terms of use agreements signed by data contributors. This data can then help further knowledge and learning and be a powerful tool for designing interoperable systems; modeling use cases (such as descriptions or flowcharts of how a user might interact with a technology tool or perform a certain task); creating maps for exploring social determinants of health or tracking health or disease data; applying artificial intelligence or “smart” applications; and identifying common pathways for access to services and provision of care.

While there are many benefits of open data, there are ethical considerations to ensure health data is handled appropriately. For example, when researchers and practitioners have access to and can compare data sets that include both social and health information, they can more readily identify and address health equity challenges in designing and delivering programs.

But wait. Are open access journals as reputable as traditional journals?
It is a misconception that open access journals do not follow rigorous peer-reviewed processes. If a journal — whether traditional or open access — is peer-reviewed, the process will follow a framework for ensuring high-quality research is published. Before submitting any manuscript, research the journal, ask colleagues who are familiar with it or request information from your local library or academic institution.

Data privacy
Many open access journals now require, at the manuscript submission stage, that authors attest that data from the research will be made publicly accessible. One example is the Dataverse Project by Harvard University, which offers a free open-source platform for data to be published and shared. It also links the data to the original research and offers users the option to download data in formats that can be inputted into statistical analysis software.

Data published as part of an open data platform need to be de-identified. This means all personally identifiable information, or PII, is removed. The National Institutes of Health defines PII as “information that can be used to distinguish or trace an individual’s identity, either alone (direct) or when combined with other personal or identifying information that is linked or linkable to a specific individual (indirect).” Examples include names, emails and home addresses. Social security numbers, driver’s license numbers, biometrics and medical or financial records are considered “sensitive PII” and require more stringent handling. The International Association of Privacy Professionals offers information and guidance on de-identifying data for open publishing.

In the health care setting, PII is referred to as protected health information, or PHI, and is governed by the Health Insurance Portability and Accountability Act, also known as the HIPAA Privacy Rule. There are times when components of this information can be shared, such as for disease tracking and surveillance, but criteria for HIPAA-permitted uses and disclosures must be adhered to. The U.S. Department of Health and Human Services provides guidance for effectively de identifying PHI when sharing data, including using “Expert Determination” to certify data and assess risk using statistical analysis or the “Safe Harbor” method, which globally removes key identifiers such as dates and social security numbers.

Another concern can be the re-identification of an individual when data sets are linked together. A study published in 2020 in Environmental Health Perspectives reviewed data and methods from 12 environmental health studies and identified data types that were vulnerable to linkages. These included data related to family members, genetics, medical care, housing and occupations. Given the large amounts of data gathered through formal research, as well as through web browsing, social networking, mobile apps, retail purchases and more, it is essential that data privacy and security standards be followed and upheld through the open data process.

Putting it all together
Access to data is essential to the Academy’s work in meeting its Research Priorities, a collection of emergent research needs that, if addressed, would have the greatest impact on knowledge advancement and empowerment of nutrition and dietetics practitioners. Work toward these priorities could be accelerated with increasing opportunities for data sharing. On eatrightPRO, members can find collections of secondary data sets as well as information on the Academy’s Nutrition Research Network.

For nutrition and dietetics professionals, especially those in research, you can put an open science lens on your work. From participating in knowledge exchange forums to pursuing publication in open access journals and submitting your data to open data portals, you can generate and advance evidence and best practices for the value of nutrition and the work of RDNs and NDTRs.

The more research and data are transparent and available, the more they can be used in collective efforts to improve programs and services, strengthen quality of care and increase positive patient outcomes. One example of this is Electronic Clinical Quality Measures, which use data from electronic health records and health information technology systems to measure the quality of care.

As a program manager or funding entity, you can put into your requirements that any research and data be made open and accessible. Not only would you have access, but so would the nutrition community and the world. And when barriers to science are broken down, we all can be better communicators of nutrition messaging that is evidence-based and showcases data utilizing graphic design and data visualization best practices.

The result: bringing the data to life, making it “here and now” and, through robust dashboards, charts and apps, putting the control of it in the hands of patients and clients, partners and fellow health professionals.

Additional Resources to Learn More

• Center for Open Science: https://www.cos.io/
• Data.Gov: https://www.data.gov/
• Federal Data Strategy: https://strategy.data.gov/
• Gates Open Research: https://gatesopenresearch.org/
• Harvard University Dataverse Project: https://dataverse.harvard.edu/
• HealthData.gov: https://healthdata.gov/
• Mind the Gap Report: https://mindthegap.pubpub.org/
• Office of Data Science Strategy (NIH): https://datascience.nih.gov/
• Open Data Barometer: https://opendatabarometer.org/
• Open Data Institute: https://theodi.org/
• Open Knowledge Foundation: https://okfn.org/opendata/
• Open Science Project: https://openscience.org/
• PLOS Open Data: https://plos.org/open-science/open-data/

References

A De-Identification Protocol for Open Data. International Association of Privacy Professionals website. https://iapp.org/news/a/a-de-identification-protocol-for-open-data/. Accessed October 4, 2021.
Boronow K, Perovich L, Sweeney L, et al. Privacy Risks of Sharing Data from Environmental Health Studies. Environ Health Perspect. 2020;128(1):17008.
Cantor M, Chandras R, Pulgarin C. FACETS: using open data to measure community social determinants of health. J Am Med Inform Assoc. 2018;25(4):419-422.
Cocoros N, Kirby C, Zambarano B, et al. RiskScape: A Data Visualization and Aggregation Platform for Public Health Surveillance Using Routine Electronic Health Record Data. Am J Public Health. 2021;111(2):269-276.
Demski H, Garde S, Hildebrand C. Open data models for smart health interconnected applications: the example of open EHR. BMC Med Inform Decis Mak. 2016;137(16).
Directory of Open Access Journals website. https://doaj.org/. Accessed October 3, 2021.
Electronic Clinical Quality Measures (eCQMs). Academy of Nutrition and Dietetics website. https://www.eatrightpro.org/practice/quality-management/quality-improvement/malnutrition-quality-improvement-initiative. Accessed October 13, 2021.
Guidance Regarding Methods for De-identification of Protected Health Information in Accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Department of Health and Human Services website. https://www.hhs.gov/hipaa/for-professionals/privacy/special-topics/de-identification/index.html#determinations. Accessed October 13, 2021.
How HIPAA Supports Data Sharing. Office of the National Coordinator for Health Information Technology website. https://www.healthit.gov/topic/interoperability/how-hipaa-supports-data-sharing. Reviewed September 6, 2018. Accessed October 13, 2021.
Levin N, Leonelli S, Weckowska D, Castle D, Dupré J. How Do Scientists Define Openness? Exploring the Relationship Between Open Science Policies and Research Practice. Bull. Sci. Technol. Soc. 2016;36(2):128-141.
Open Access Policy FAQ. Gates Foundation website. https://www.gatesfoundation.org/about/policies-and-resources/open-access-policy-faq. Accessed October 22, 2021.
Open Data in 60 Seconds. World Bank Open Government Data Toolkit website. http://opendatatoolkit.worldbank.org/en/open-data-in-60-seconds.html. Accessed September 22, 2021.
Open Data: Agencies Need Guidance to Establish Comprehensive Data Inventories; Information on Their Progress is Limited. U.S. Government Accountability Office website. https://www.gao.gov/products/gao-21-29. Accessed October 4, 2021.
Payne P, Lele O, Johnson B, Holve E. Enabling Open Science for Health Research: Collaborative Informatics Environment for Learning on Health Outcomes (CIELO). J Med Internet Res. 2017;19(7):e276. Published July 31, 2017.
Peregrin T. Social Determinants of Health: Enhancing Health Equity. J Acad Nutr Diet. 2021;121(6):1175-1178.
Public Access Policy. National Institutes of Health website. https://publicaccess.nih.gov/. Accessed October 13, 2021.
The Dataverse Project website. https://dataverse.org/. Accessed October 13, 2021.
Toolkit for Patient-Focused Therapy Development. United States Department of Health and Human Services website. https://toolkit.ncats.nih.gov/glossary/personally-identifiable-information/. Accessed December 10, 2021.
Transparency and Best Practice. Directory of Open Access Journals website. https://doaj.org/apply/transparency/. Accessed September 22, 2021.

How It Happens
Normally, the small intestine contains very little bacteria; the concentration of microbes increases progressively down the small bowel to the colon, where approximately 38 trillion microbes live. With SIBO, bacteria are displaced from the colon, increasing the number and types of microbes in the small intestine and causing excess fermentation, malabsorption or inflammation.

SIBO is a secondary condition, meaning it occurs in response to something else, such as a disease or alteration to the small bowel. There are several reasons SIBO may develop: Post-surgical causes may include resections or anastomotic adhesions or strictures. Medications can contribute; for instance, opioids slow the bowel and anticholinergics alter gastric acid production. Structural causes may include diverticula of the small intestine or fibrous bands. Additionally, small intestine function can be altered by chronic inflammatory diseases, such as lupus, diabetes or chronic pancreatitis.

Any of these factors can disrupt the mechanisms that keep the small intestine “clean” and introduce bacteria that normally wouldn’t be there. Innate cleaning mechanisms of the small intestine include secretion of stomach acid, pancreatic excretions and the migrating motor complex, a cyclical four-stage process that occurs during fasting and includes contractions, which push residual food to the colon. Additionally, the ileocecal valve keeps out unwanted microbes by blocking the connection between the colon and the small intestine.

Symptoms
Symptoms associated with SIBO may include abdominal distention and bloating. Abdominal distention grows progressively worse throughout the day and is usually worst in the evening. Abdominal pain or discomfort also is common, though intense pain is not usually associated with SIBO. Feeling full quickly, “brain fog” or fatigue, especially after eating, are other possible signs of SIBO. While weight loss has long been a symptom associated with SIBO, weight gain is now a recognized symptom as well. People with SIBO also may experience nausea, diarrhea or constipation (which can occur depending on the type of overgrowth present).

SIBO or IBS?
RDNs may encounter SIBO in the context of irritable bowel syndrome, as many of the symptoms overlap. Although data varies on the prevalence of SIBO in people with IBS, a recent meta-analysis reviewed 25 case-controlled studies with more than 3,000 IBS patients and 3,000 controls without IBS. Researchers found the prevalence of SIBO in subjects with IBS was 31% and only 9% in the control group, meaning people with IBS are more likely to have SIBO. Another study found that SIBO was more prevalent in IBS patients with diarrhea than those with constipation.

Dietary Interventions
RDNs can guide patients and clients on how to best manage symptoms through diet modifications. Though many diet therapies have been suggested — such as the Specific Carbohydrate Diet, SIBO Bi-Phasic Diet, Gut & Psychology Syndrome Diet, low FODMAP diet and Cedars-Sinai Low Fermentation diet — evidence is lacking on whether any of these diets is best for someone with SIBO.

In February 2020, the American College of Gastroenterology released clinical guidelines for SIBO. They recommend eating fewer fermentable foods, including “alcohol sugars and other fermentable sweeteners such as sucralose.” Additionally, the guidelines suggest reducing fiber consumption and avoiding prebiotics such as inulin.

Some practitioners suggest incorporating meal spacing, which means waiting at least five hours between meals to allow as much time as possible for the migrating motor complex to occur. This gives more time for contractions to push residual food and bacteria through the small intestine to the colon.

Key nutritional concerns of SIBO include reduced fat absorption and, consequently, fat-soluble vitamin deficiencies as well as iron, thiamin and B₁₂ deficiencies. There is not enough evidence to support the use of probiotics in people with SIBO, and some studies suggest probiotics may worsen symptoms.

After a physician’s diagnosis, RDNs should first consider removing fermentable carbohydrates from the patient’s or client’s diet, then reintroducing them as tolerated to create an individualized eating plan that can be maintained over the long term. Consider trialing meal spacing and be mindful of potential nutrient deficiencies.

Additionally, practicing a multidisciplinary approach can lead to better overall care. This means working alongside a patient’s or client’s gastroenterologist, primary care physician and any other health care professionals. Working as a team can create seamless care and encourage patients and clients to follow nutrition recommendations for best management of their symptoms.

Learn more about the testing for SIBO, diagnostic criteria and the rate of recurrence, plus discover the three pillars of management — including considerations for an elemental diet — by watching the 2021 Food & Nutrition Conference & Expo™ session Diagnosis, Treatment and Dietary Interventions for Small Intestinal Bacterial Overgrowth: An Up-To-Date Practical Review.

References

Anastomotic Stenosis (Stricture) After Gastric Bypass Surgery. University of Rochester Medical Center website. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=134&contentid=155. Accessed November 22, 2021.
Anticholinergic Agents. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda(MD); 2017.
Deloose E, Janssen P, Depoortere I, Tack J. The migrating motor complex: control mechanisms and its role in health and disease. Nat Rev Gastroenterol Hepatol. 2012;9(5):271-285. Published March 27, 2012.
Fogt E, Hardy A, Rezaie A. Diagnosis, Treatment and Dietary Interventions for Small Intestinal Bacterial Overgrowth: An Up-To-Date Practical Review. Food & Nutrition Conference & Expo™ session. Presented October 18, 2021.
Pimentel M, Saad R, Long M, Rao S. Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020(115)(2);165-178.
Rao SSC, Bhagatwala J. Small Intestinal Bacterial Overgrowth: Clinical Features and Therapeutic Management. Clin Transl Gastroenterol. 2019;10(10):e00078.
Sizar O, Genova R, Gupta M. Opioid Induced Constipation. StatPearls Publishing. Treasure Island(FL); 2021.
Takakura W, Pimentel M. Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome – An Update. Front Psychiatry. 2020;11:664.

“Many of my clients come to me already diagnosed with PCOS but share a similar story of years with symptoms managed by birth control or completely dismissed,” says Olivia Wagner, MS, RDN, LDN, IFNCP, owner of Chicago-based Liv Nourished, which offers functional women’s nutrition for PCOS and irregular or missing periods.

PCOS symptoms can present differently. Many people with PCOS experience irregular menstrual cycles, ovarian cysts or increased follicle count on the ovaries (diagnosed via ultrasound) and hirsutism (increased body and facial hair growth more characteristic in males). Up to 80% of those with PCOS experience excess androgen levels, which lead to hirsutism, acne and changes in hair growth patterns. Half of those with PCOS experience overweight or obesity.

Women with PCOS are at an increased risk of infertility (15 times more likely), Type 2 diabetes (4 times more likely) and insulin resistance, cardiovascular disease, certain types of cancer, eating disorders and mental health conditions including depression and anxiety. An estimated 50% of people with PCOS will develop metabolic syndrome.

Diagnosing PCOS

Several organizations have published recommendations for PCOS over the years, including in 1990, when the first international conference was held at the National Institutes of Health. Here, initial diagnostic criteria for PCOS were developed and used until 2003, when a group of experts created the Rotterdam criteria. According to these criteria, two of three clinical findings must be present for a physician to diagnose PCOS: ovulatory dysfunction, polycystic ovaries and an excess of androgen hormones. In 2018, as a result of a collaboration among 37 international organizations in 71 countries, an International Evidence-Based Guideline for the Assessment and Management of PCOS was released. It presents 166 recommendations and practice points for clinicians and dedicates a chapter to lifestyle interventions for women with PCOS. It is unknown how many U.S. physicians have adopted this guideline.

Some RDNs believe the traditional criteria used by physicians to diagnose PCOS can have limitations. Melissa Groves Azzaro, RDN, LD, owner of The Hormone Dietitian LLC and author of A Balanced Approach to PCOS explains, “Rotterdam is definitely flawed — ovaries can appear polycystic for several reasons, including puberty, hypothalamic amenorrhea and after going off hormonal birth control.”

Wagner supports the new international guidelines, which she says support aspects of the Rotterdam criteria “but also recommend tighter diagnostic criteria requiring both hyperandrogenism and irregular cycles. The newer guidelines are more specific regarding how ultrasounds are used and interpreted.”

Because of the potential reductions in quality of life and comorbidities such as CVD, Type 2 diabetes and reproductive problems, the scientific community has focused on PCOS diagnosis and treatment in adolescents. Some pediatric guidelines indicate PCOS diagnosis in adolescents cannot be made until two years post-menarche, while others, including the new international guideline, suggest adolescents should be assessed as at-risk if they experience menstrual irregularity after just one year. In 2019, a group under the International Consortium of Pediatric Endocrinology created an update of recommendations specifically for adolescents.

New research funded by the NIH suggests there may be distinct subtypes of PCOS, which could provide insight into diagnosis and treatment in the future. The study included an analysis of hormonal and anthropometric data and the genes of close to 900 individuals diagnosed with PCOS based on NIH and Rotterdam criteria. These preliminary findings were based solely on cases in the U.S. and individuals of European ancestry.

Weight-Related Concerns

Studies surveying people with PCOS show weight management and difficulty losing weight are their foremost concerns. The primary intervention for PCOS has been advice to lose weight to lessen the effects of insulin resistance that often accompanies the condition. Even modest weight loss (5% to 10% of initial body weight) can reduce PCOS symptoms, decrease androgen production, increase fertility and improve both insulin sensitivity and ovulatory function.

Amy Plano, RD, CDE, MS, CDN, owner of The PCOS Dietitian and author of Treating PCOS with the DASH Diet: Empower the Warrior from Within, describes her approach to weight loss: “There is so much research backing the benefits of even modest changes in weight for this population from a symptom standpoint. So, weight loss — when warranted — is a no-brainer. Looking at the big picture is most important. I help women lose weight so they can qualify for in vitro fertilization and accomplish their dream of having a family.”

Wagner takes an approach that de-emphasizes weight loss as a focus but finds many of the changes she works with clients on ultimately lead to a reduction in weight, if appropriate and a goal of the client. “In my practice, I prioritize features like blood sugar balance, anti-inflammatory diet modifications and addressing other imbalances that could be adding to inflammation and overall expression of PCOS,” she says. “As a result of these shifts, weight loss is typical. We know that fat loss improves insulin resistance and estrogen metabolism, and improved insulin resistance also improves testosterone levels. Weight loss and fat loss can be supportive, but for me, it is a secondary goal in overall treatment.”

However, people with PCOS may have trouble losing weight because of metabolic changes associated with the condition. Also, studies show people with PCOS experience food cravings, increased appetite, impaired impulse control and body dissatisfaction. This may worsen the likelihood of disordered eating and mental health problems. “PCOS is a lifelong condition, so any changes we recommend have to be sustainable,” Azzaro says. “It is also important to remember that the incidence for disordered eating is exponentially higher in people with PCOS and restrictive diets are not the answer.”

Studies have shown that people with PCOS have higher rates of and higher odds of moderate and severe depression and anxiety. Research on the incidence of eating disorders in the PCOS population has found an increased prevalence of binge eating behavior. Women with bulimia nervosa and binge eating disorder are more likely to have PCOS symptoms and polycystic ovaries; more research is needed to better understand a possible association between eating disorders and PCOS.

A cross-sectional study in Australia found that disordered eating — but not eating disorders — was more prevalent in women with PCOS compared to the control group. Researchers concluded that health care professionals should screen all women with PCOS for disordered eating patterns.

The new international guideline states that all health care professionals should be aware of the increased prevalence of eating disorders and disordered eating that may be associated with PCOS. The guideline also says people with PCOS can experience benefits in body composition and metabolic status separate from weight loss. Azzaro agrees and says, “I question whether it was the weight loss itself or the behaviors that led to the weight loss that actually impacted symptoms and markers. I think a lot of doctors don’t acknowledge how damaging it is to tell women with PCOS to ‘just lose weight,’ given the context of hormonal imbalances that make weight loss more difficult, such as insulin resistance, high androgens, high cortisol and DHEA, and inflammation.

Treating PCOS

Most clinical guidelines suggest lifestyle modifications can serve as the first line of treatment for PCOS. Pharmacological treatment also is available and often includes combined oral contraceptive pills or anti-androgen medications for those with irregular menstrual cycles and high androgen levels, metformin for blood sugar management and insulin resistance, and ovulation induction medications for those with infertility related to PCOS.

Limited studies suggest dietary modifications, physical activity and behavioral therapy delivered by a multidisciplinary team that includes a registered dietitian nutritionist and health psychologist may yield better success with weight loss, patient satisfaction and continuing to seek care with their provider for PCOS management. However, a survey-based study of 722 women with PCOS found less than 10% of participants reported working with an RDN.

Plano agrees with taking a multidisciplinary approach and does so in her practice. “PCOS is multifactorial and impacts so many different systems in the body. It is not just a hormone issue,” she says. “Having a strong referral team in place is absolutely critical. I work closely with therapists, marriage and family counselors, endocrinologists, dermatologists and OB/GYNs.” Azzaro says a multidisciplinary approach is “absolutely integral. It takes a village. In fact, one of the things I like most about the [international guideline] is that it highlights the need for people with PCOS to have a full support team, including primary care, gynecology, endocrinology, diabetes care, dietitians, mental health professionals, personal trainers, estheticians and more.”

Dietary interventions
Plano explains her approach to personalizing the diet for clients with PCOS: “First I look at improvements in quality, then I work on decreasing the caloric intake, if necessary. I don’t cut out any food groups but instead do my best to help them gradually scale back the quantity of carbohydrates they consume. I like to aim for 40% or fewer total calories coming from carbohydrates. I elevate the protein to promote satiety and encourage heart-healthy fats.

The international guideline offers dietary intervention recommendations for women with PCOS, which include a focus on balanced dietary approaches tailored for food preference, flexibility and individual needs. While the dietary interventions list an energy deficit of 30% (or 500 to 750 calories per day) as a consideration for those with excess weight, they also state that all women, regardless of age, should follow general healthful eating principles. The guideline also says weight-related stigma, self-esteem and body image need to be taken into consideration. All health care professionals should be respectful and considerate when approaching discussions about weight, seek permission before taking weight measurements and focus on the emotional well-being of patients and clients.

An important strategy for treating people with PCOS is creating a dietary plan to help reduce insulin resistance. Published in 2013, a systematic review of five studies found that, although several diets (monounsaturated fat-enriched, low-glycemic index, low-carbohydrate, high protein) yielded various health benefits, it was ultimately weight loss that seemed to improve PCOS symptoms the most, regardless of the diet’s composition. These researchers pointed to reducing total caloric intake rather than adjusting individual aspects within a dietary pattern.

A more recent systematic review of 19 clinical trials showed that diet can significantly improve insulin resistance and body composition for people with PCOS. Specifically, the Dietary Approaches to Stop Hypertension diet and eating patterns that created a 500-calorie deficit performed best. Researchers found that a longer duration of these dietary interventions yielded more improvements in insulin resistance and body composition.

Macronutrient modification including low-glycemic or low-carbohydrate diets have limited evidence for effectiveness in treating PCOS. One small study from 2005 examining the use of a ketogenic diet for six months saw significant improvements in weight, hormonal profiles and fertility. Other studies, including a systematic review, have shown that reductions in carbohydrate consumption (from 55% to 41% of total energy intake, in some studies) improved the metabolic effects of PCOS. All these studies are small and have limitations, so more research is needed to understand whether carbohydrate restriction or reduction could be beneficial for people with PCOS.

Surveys about health-related knowledge, beliefs and self-efficacy of women with PCOS, compared to a control group, found those with PCOS perceived fewer benefits from healthy lifestyle behaviors such as diet and exercise in relation to weight gain, and only 47% of the PCOS group reported attempting to follow an overall balanced diet. “When it comes to dietary support for PCOS, my approach is a whole-food diet focused around blood sugar stability, high plant-based fiber and inclusion of macronutrient-balanced and anti-inflammatory meals while addressing any individual root imbalances with food as medicine,” Wagner says.

Exercise interventions
Exercise guidelines for women with PCOS are similar to those without. Adolescents should aim for 60 minutes or more of physical activity per day with strength training three times per week, and adults should get 150 minutes per week of moderate-intensity activity or 75 minutes of vigorous activity (or a combination of both) and two non-consecutive days of strength training activities. The international guideline for PCOS suggests activity be performed in 10-minute or longer bouts and that patients and clients take 10,000 steps per day. Recommendations for those aiming for modest weight loss or focusing on weight regain prevention are 250 minutes per week of moderate-intensity activity or 150 minutes of vigorous activity (or a combination of both) and two non-consecutive days of strengthening activities.

In a systematic review and meta-analysis about exercise for managing PCOS, effects from exercise included statistically significant benefits to fasting insulin, insulin resistance markers, total and low-density lipoprotein cholesterol and triglycerides. The greatest improvements were seen in study participants with overweight or obesity. However, the authors cautioned about interpreting the findings due to study limitations including low-quality evidence.

One systematic review and meta-analysis found that when assessing exercise duration (ranging from six to 26 weeks), exercise intensity mattered more than quantity for health outcomes, including increases in V0₂ peak (used to assess a person’s physical activity limits, this is the highest value of oxygen rate attained during a high-intensity exercise test), reduced insulin resistance markers and reduced waist circumference. The greatest benefit was seen in vigorous-intensity exercise either alone or combined with a dietary plan, advice or guidance.

Behavioral therapy interventions
A review of evidence included in the new international guideline for PCOS indicated behavioral interventions yielded better outcomes in weight management for adolescents than compared to a placebo group, as well as when used in combination with dietary and exercise interventions. One study showed that adolescents who received behavioral interventions from a multidisciplinary care team with an RDN, health psychologist, gynecologist and endocrinologist experienced enhanced weight loss when combined with dietary consultations.

Role of RDNs

There are proven benefits to people with PCOS receiving early access to an RDN. While studies show a multidisciplinary approach to PCOS treatment yields the best outcomes, they also highlight barriers to including RDNs in the care team, including insurance reimbursement and financial limitations for patients and clients, lack of referrals for nutrition education and lack of knowledge of PCOS and the potential benefit of lifestyle interventions. Studies show knowledge gaps in health care professionals can lead to delays in diagnosing and caring for people with PCOS and to patients and clients seeking less qualified or low-quality information online for support. RDNs working with populations at risk for PCOS should stay abreast of current research.

When approaching weight management for people with PCOS, RDNs should consider emotional well-being, individual dietary and lifestyle preferences, and unique, cultural and socioeconomic values or needs. Using a patient-centered approach that is weight-inclusive is important when working with people with PCOS. Plano supports this approach and adds, “No matter what the dietary protocol, the individual and their food preferences and lifestyle are paramount. Working around my guidelines is second to the client’s personal needs.”

Wagner also supports personalized care and holistic support. “I find that establishing an empowered mindset toward their health is essential for best outcomes,” she says. “With a focus on inclusion versus exclusion and empowering them in their diet and lifestyle, it is easier to adopt daily practices that they truly feel aligned with that are going to support their health with PCOS long-term.”

References

Abdalla M, Deshmukh H, Atkin S, Sathyapalan T. A review of therapeutic options for managing the metabolic aspects of polycystic ovary syndrome. Therap Advance Endocrine Metab. 2020;11:2042018820938305.
Dapas M, Lin FT, Nadkarni GN, et al. Distinct subtypes of polycystic ovary syndrome with novel genetic associations: An unsupervised, phenotypic clustering analysis. PLoS medicine. 2020;17(6):e1003132.
Dokras A, Stener-Victorin E, Yildiz B, et al. Androgen Excess-Polycystic Ovary Syndrome Society: position statement on depression, anxiety, quality of life, and eating disorders in polycystic ovary syndrome. Fertil Sterile. 2018;109(5):888-99.
Garad RM, Teede HJ. Polycystic Ovary Syndrome: Improving policies, awareness and clinical care. Current Opinion in Endocrine and Metabolic Research. 2020.
Geier L, Bekx M, Connor E. Factors contributing to initial weight loss among adolescents with polycystic ovary syndrome. J Ped Adolescent Gyn. 2012;25(6):367-70.
Gibson-Helm M, Teede H, Dunaif A, Dokras A. Delayed diagnosis and a lack of information associated with dissatisfaction in women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2017;102(2):604–612.
Goodman N, Cobin R, Futterweit W, Glueck J, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and androgen excess and PCOS society disease state clinical review: guide to the best practices in the evaluation and treatment of polycystic ovary syndrome-part 1. Endocrine Practice. 2015;21(11):1291-300.
Goodman N, Cobin R, Futterweit W, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Androgen Excess and PCOS Society disease state clinical review: guide to the best practices in the evaluation and treatment of polycystic ovary syndrome-part 2. Endocrine Practice. 2015;21(12):1415-26.
Goss AM, Chandler-Laney PC, Ovalle F, et al. Effects of a eucaloric reduced-carbohydrate diet on body composition and fat distribution in women with PCOS. Metabolism. 2014;63(10):1257-64.
Gower BA, Chandler‐Laney PC, Ovalle F, et al. Favourable metabolic effects of a eucaloric lower‐carbohydrate diet in women with PCOS. Clinic Endocrine. 2013;79(4):550-7.
Ibáñez L, Oberfield SE, Witchel S, et al. An International Consortium update: pathophysiology, diagnosis, and treatment of polycystic ovarian syndrome in adolescence. Horm Res Paediatr. 2017;88(6):371–395.
Jarrett BY, Lin AW, Lujan ME. A commentary on the new evidence-based lifestyle recommendations for patients with polycystic ovary syndrome and potential barriers to their implementation in the United States. J Acad Nutr Diet. 2019;119(2):205-10.
Kite C, Lahart IM, Afzal I, et al. Exercise, or exercise and diet for the management of polycystic ovary syndrome: a systematic review and meta-analysis. Syst Rev. 2019;8(1):51.
Lin A, Dollahite J, Sobal J, Lujan M. Health-related knowledge, beliefs and self-efficacy in women with polycystic ovary syndrome. Hum Reprod. 2018;33(1):91–100.
Mavropoulos J, Yancy W, Hepburn J, Westman EC. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study. Nut Metab. 2005;2(1):1-5.
McGrice M, Porter J. The effect of low carbohydrate diets on fertility hormones and outcomes in overweight and obese women: A systematic review. Nutrients. 2017;9(3):204.
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Moran LJ, Tassone C, Boyle J, et al. Evidence summaries and recommendations from the international evidence‐based guideline for the assessment and management of polycystic ovary syndrome: Lifestyle management. Obesity Rev. 2020;21(10):e13046.
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Whether you are a student, newly minted registered dietitian nutritionist or nutrition and dietetics technician, registered or a seasoned pro, what you share online can change the trajectory of your career — for better or worse.

According to employment website CareerBuilder, seven in 10 employers use social media to research candidates during the hiring process. Employers are not only seeking talented people to add to their team, but also looking to avoid a liability or to see if you post inappropriate content.

When was the last time you thought about your digital footprint? Or how others might perceive your online activity? Is it possible that you lost out on a job or other opportunity without even knowing it, based on something you (or even someone else) put on the internet?

On social media, it’s easy to hit “like” on a meme or quickly chime in on controversy. Online platforms are an ideal way to connect, after all. However, one-on-one conversations are no longer left at the office water cooler. Instead, they are indelibly imprinted on the internet for any and all to see — including potential employers.

Luckily, there are ways to make social media work for you so that jobs will flow your way, not away.

Keep It On-Brand

Define your personal brand. Perhaps you’ve heard of branding, but can you verbalize yours? While there are differences between your personal and professional personas, the key is defining how you want to present yourself to the world.

This can span from staying in your lane of professional expertise to handling sensitive topics such as politics or social justice issues. It’s also your tone. Will you come across as accessible and warm, candid and casual, or a little quirky?

Prepare to accept the consequences and rewards of your brand’s position. Because some issues will be controversial or divisive, you likely will have support and opposition on both sides. Decide ahead of time how you will show up and engage based on how it might impact your goals.

Know that people are watching — and it’s not just your followers. Potential customers, clients and employers are paying attention. They want to learn about you and see if there’s a good fit or potential relationship. Although employers often are screening for red flags, this is an opportunity to impress them, too.

Structure social media as an online portfolio to show off your creativity. If you excel at translating complex nutrition topics into easy-to understand tidbits for consumers, create infographics showcasing this skill. If you’re a pro at cooking while sharing compelling stories, highlight those skills with short videos. And if you’ve got the gift of gab, create a podcast or start a show on an audio platform.

Curate a feed of your best work and what you want to be known for. It’s all in your hands.

Keep It Clean

Being clear about your brand helps keep your social media on point. Use your brand as a compass.

Curate the content you share. As a professional, you probably check for sensitive language or images that might offend others. But consider taking a few more steps. Before posting, ask yourself: Is this image aligned with my brand? Is this post helpful? Does this tweet represent my unique viewpoint? Or does it subscribe to groupthink (where you adopt the opinion of a majority just to get along or to boost engagement)?

If you manage an online group, page or forum, consider setting ground rules. This is not to limit free speech but to set expectations and foster a respectful, professional environment. For example, you might require people to agree to communications guidelines before joining a Facebook group or saving a story highlight on Instagram to make your expectations clear.

Consider taking controversial conversations offline. Decide how to handle controversial online discussions. It’s ok to ignore some comments, but when constructive criticism and inquisitive remarks are posted in a respectful manner, they can present an opportunity to build an engaged audience.

Nothing online is truly private. Remember that a person can snap a screenshot or otherwise save and share a one-to-one chat. Deleted content is re-discoverable, too. Social media management software, background check agencies and digital forensic recovery techniques can uncover anything ever shared on the internet.

Likes, retweets and reposts are seen as a stamp of approval. Credentialed nutrition and dietetics practitioners are expected to share only credible, science-based information. Take time to vet all content and share and support only what you know to be accurate. Before double-tapping to like a post, consider the source and the original poster’s motivation for sharing the content. Does it align with your brand and messaging? Avoid conversations that include language or subjects you wouldn’t want to be associated with in the future.

When possible, remove negative content. Although scrubbing content doesn’t erase it from the internet, in some instances, it may make sense to delete posts; for example, it might be useful in online forums where future commenters could keep a controversy going.

There are options to help mitigate this issue on your channels: Disable or limit comments, untag photos and change your settings to prevent future tagging. Keep professional civility in mind and remember that taking the higher road often can quell an inflammatory conversation. You’ll sleep better at night and keep your professional reputation intact.

Keep It Ethical and Legal

Although you might not break any laws with an online rant, there still is a risk of committing slander, libel or defamation of character. As a member of the Academy of Nutrition and Dietetics or a practitioner credentialed by the Commission on Dietetic Registration, you are bound by the Academy’s/CDR’s Code of Ethics for the Nutrition and Dietetics Profession. Consult the Code to identify potential conflicts of interest and what constitutes professionalism, social responsibility and evidence-based practice.

Knowing and understanding the basics of copyright law can help as well. The “fair use” policy allows limited usage of certain copyrighted content, such as some quotes and photos, without needing the owner’s permission and without paying fines. However, you do need express permission to use most images and videos. Photos are protected by copyright from the moment they are taken, whether or not the work is registered with the U.S. Copyright Office. Sharing from an original creator’s account on social media is generally appreciated, but taking and using content on your own channels or a website might be an infringement.

It’s especially important to avoid HIPAA violations, such as posting images or videos of patients without consent, sharing details that could lead to identifying an individual or gossiping about patients. Even if you don’t use names, seeing that you conduct public conversations about clients may be enough to turn off a potential employer.

Being paid to promote a food or product is not against any rules, but disclosure is key. Follow the Academy’s/CDR’s Code of Ethics and Federal Trade Commission’s guidelines. Not disclosing erodes trustworthiness and is simply bad practice — plus, it can potentially cost you future opportunities.

Action Steps: Use social media to grow your career. Social media is here to stay. It’s often where people look first to find out more about you. Use it to your advantage:

Choose online platforms wisely.

• Create a space for your audience where they know what to expect and where they can feel safe and supported, as well as entertained and educated.
• Create an online persona that is the best reflection of you. Use social media as a space to show off the best of what you have to offer and a place to tell your story how you want it to be told.
• Connect with a potential employer or client you’re pursuing. Following on social media is an ideal way to learn a company’s culture to see if you’d be a good fit.

Before you post, stop and think.

• Before pressing the publish button, assess your state of mind. What role do your emotions play in the post? Will you feel good about this post in a day or a week? If you have doubts, consider waiting or asking a trusted colleague to review it before you share it far and wide.

Create a feed that feeds you.

• Unfollow people, brands and pages that don’t make you feel good.
• Shake up the algorithm. Choose positive and encouraging people to follow within and outside of food and nutrition. It might spark your creativity and help you show up as your best social self.

References

Code of Ethics for the Nutrition and Dietetics Profession. Academy of Nutrition and Dietetics website. Accessed July 19, 2021.
Disclosures 101 for Social Media Influencers. Federal Trade Commission website. Accessed July 26, 2021.
Fair Use (FAQ). United States Copyright Office website. Accessed July 26, 2021.
Food & Nutrition Magazine Pledge of Professional Civility. Food & Nutrition Magazine website. Accessed July 19, 2021.
Helm J, Jones RM. Practice Paper of the Academy of Nutrition and Dietetics: Social Media and the Dietetics Practitioner: Opportunities, Challenges, and Best Practices. J Acad Nutr Diet. 2016;116:1825-1835.
More Than Half of Employers Have Found Content on Social Media That Caused Them NOT to Hire a Candidate, According to Recent CareerBuilder Survey. CareerBuilder website. Published August 9, 2018. Accessed June 10, 2021.

The importance of skin protection
Spending time outside might boost your mood, but without proper skin protection, time outside can have unfavorable consequences, such as sunburn, increased risk of skin cancer and premature skin aging, all caused by ultraviolet radiation from the sun.

Sunlight produces three types of UV rays: UVA, UVB and UVC. UVA rays penetrate the skin deepest and contribute to premature aging, such as sunspots, wrinkles and sagging. There are two forms of UVA: UVA1 and UVA2; UVA1 rays penetrate the skin deeper than UVA2. Of the three main types of UV rays, UVA accounts for 95% of UV exposure, of which UVA1 accounts for 75%. UVB rays produce sunburns and are largely responsible for skin cancer. The most dangerous type, UVC, is blocked by the earth’s ozone layer but also is present in some artificial light sources, such as mercury lamps or lasers.

And while many people think sun protection is only relevant on sunny days, UV rays can penetrate through clouds and be reflected off snow, sand, concrete and water, and UVA rays specifically can penetrate through glass, making sun protection essential year-round.

Unprotected skin can be damaged in as little as 15 minutes outside. Because of this, the American Academy of Dermatology recommends getting vitamin D from foods, including natural sources, such as salmon, eggs and mushrooms exposed to UV light, and those fortified with vitamin D, such as orange juice, dairy products and cereals.

Skin tone and susceptibility
The Centers for Disease Control and Prevention reported 46.3% of non-Hispanic white adults experienced a sunburn in 2015. In contrast, 22.4% of Hispanic people and 9.9% of Black people experienced a sunburn the same year. A lower incidence of sunburn among people with darker skin tones is largely due to melanin, a skin pigment that helps block harmful UV rays. The darker a person’s skin tone, the more melanin it contains, whereas lighter skin tones have less melanin.

While melanin helps protect against UV rays, protecting skin from the sun through other measures is important for people of all skin tones. Some studies have shown that despite having lower incidences of melanoma, a form of skin cancer, Black people have a lower five-year melanoma survival rate compared to white people (67% and 92%, respectively) and Black people and Hispanic people are more likely to have a late-stage melanoma diagnosis compared to white people. Some dermatologists speculate medical bias may play a role, in addition to a public misconception that only white people develop skin cancers and sun damage. People with darker skin tones may not burn as easily, but skin cancer and sun damage affect people of all races, ethnicities and skin tones.

Although research is still early and ongoing, some studies suggest certain compounds in foods and beverages may help boost the skin’s defenses against UV rays. Carotenoids, vitamin C and vitamin E, omega-3 fatty acids and some polyphenols are a few notable compounds showing potential benefits, such as delaying or preventing sunburns and redness and helping prevent or reduce signs of aging.

Carotenoids

Lycopene
Studies suggest lycopene may have photoprotective benefits, meaning it offers skin protection against UV light. Lycopene, a pigment found in red, yellow and orange fruits and vegetables, can be obtained through tomatoes, watermelon, pink guava, red oranges, pink grapefruit, rosehips, carrots, bell peppers and papaya. Lycopene is easier for the body to use when the source has been heated, meaning pasta sauce and tomato juice offer more lycopene than raw tomatoes.

Several studies have shown that consuming 10 to 16 milligrams of lycopene per day in the form of supplements or tomato paste with olive oil may offer photoprotective benefits. Compared to placebo groups, skin redness from exposure to UV light was significantly lower after consuming 10 to 16 milligrams each day for 10 to 12 weeks. Some of these studies included only participants with fair skin tones, while others did not list skin tone as an inclusion or exclusion criteria.

A delay in skin reddening after UV exposure suggests lycopene may help boost skin’s defenses against UVB rays, which are most responsible for an increased risk of skin cancer. However, one study sought to find if lycopene offered protection against UVA1 rays and discovered certain biomarkers associated with oxidative damage, collagen breakdown and inflammation from UVA1 were reduced after supplementing with 10 grams of lycopene soft gels daily for 12 weeks.

Astaxanthin
Astaxanthin is a red pigment responsible for the color of many marine animals, such as salmon, lobster and shrimp, plus some bacteria and algae. A 2019 review and a 2020 systematic review of 11 clinical trials found taking 3 to 6 milligrams of astaxanthin supplements per day for four to 16 weeks helped protect skin against UV-induced damage. Studies also showed astaxanthin minimizes effects of aging, such as wrinkles and sunspots. However, most of the studies conducted so far have had small sample sizes with primarily female Japanese participants. Therefore, more research and a more diverse study population is needed to further substantiate astaxanthin’s role in sun protection.

Beta-carotene
The pigment beta-carotene is found in yellow and orange fruits and vegetables including carrots, sweet potatoes and winter squash, and in leafy green vegetables such as spinach and lettuce.Research investigating potential sun-protective benefits of beta-carotene date back to the 1970s.

A 2020 review found that beta-carotene had sun-protective benefits at doses ranging from 12 to 180 milligrams a day. A seemingly more important factor was how long participants took the doses — not necessarily how much.

Beta-carotene may provide some sun protection at a minimum dose of 12 milligrams per day when taken for at least seven weeks. Studies show participants who followed this regimen could be exposed to UV rays longer before getting sunburned compared to those who weren’t taking beta-carotene. However, some of these studies had only participants with fair skin tones, while others did not mention if all participants had a similar skin tone.

A few animal studies found that beta-carotene reduced the risk of skin cancer, but human studies have not been able to reproduce the same results. For instance, one large human study had participants supplement with 50 milligrams daily and saw no significant reductions in skin cancer risk after five years.

Anyone considering beta-carotene supplements should take caution — when it comes to dose, more may not be better.

Two studies found that higher doses of beta-carotene (20 to 30 milligrams) taken over several years increased the risk of lung cancer in some people.

Ingesting a mixture of lycopene, beta-carotene and lutein also has shown to help protect skin against UV rays. One study found that 8 milligrams of the mixture taken daily for 12 weeks was as effective at protecting skin from UV rays as taking 24 milligrams of beta-carotene alone. Another study found that a mixture of beta-carotene (6 milligrams), lycopene (6 milligrams), vitamin E (10 milligrams) and selenium (75 micrograms) helped prevent sunburn and skin damage after seven weeks.

Lutein and Zeaxanthin
These orange and yellow pigments are found in foods such as cantaloupe, corn, carrots, peppers and eggs. Other sources include kale, spinach, broccoli and peas. Although lutein and zeaxanthin may be better known for supporting eye health, early research suggests they may help protect skin against UV rays. When supplementing with lutein and zeaxanthin, skin took longer to turn red under UV light. While results are promising, they are primarily from animal studies. Therefore, more research is needed.

Vitamins C and E

Most Americans get vitamin C from citrus fruits, tomatoes and tomato juice, but other sources include red and green bell peppers, kiwifruit, broccoli, Brussels sprouts and strawberries. Sources of vitamin E include vegetable oils, nuts and seeds, spinach, broccoli and kiwifruit.

While there is limited evidence (mostly from animal studies) suggesting topical vitamin C can help limit skin damage from UV exposure, there is not much evidence suggesting oral vitamin C supplementation can do the same. Likewise, while many studies have tested the potential photoprotective benefits of oral vitamin E supplementation, the results so far suggest it may not offer much protection. However, when vitamin C is combined with vitamin E, studies show it may reduce the rate at which skin burns and reduce the amount of DNA damage after UV exposure.

In one double-blind placebo-controlled study, participants took 2 grams of vitamin C with 1,000 international units of vitamin E. After eight days, researchers found it took longer for participants to get a sunburn than it did before they took the supplements. Another study had participants take 1 gram of vitamin C and 500 IU of vitamin E for three months and found similar results. For perspective, the current recommended daily dietary allowance of vitamin C is 90 milligrams for males 19 and older and 75 milligrams for females 19 and older (85 milligrams for pregnant women and 120 milligrams for those who are lactating). The current recommended daily dietary allowance of vitamin E is 15 milligrams for males and females 14 and older, plus those who are pregnant, and 19 milligrams for people who are lactating.

Omega-3s

Some studies suggest supplementing with omega-3 polyunsaturated fats, particularly eicosapentaenoic acid, or EPA, may help protect the skin against UV damage. Common food sources of omega-3 fatty acids include fatty fish such as salmon, mackerel, herring and sardines.

During one randomized controlled-trial, participants took 4 grams of either purified (95%) EPA supplements or oleic acid supplements (a monounsaturated omega-9 fatty acid) for three months. At the end of the trial, the EPA group saw a significant reduction in UVB-induced redness and DNA damage. Another trial involved participants taking fish oil capsules (2.8 grams of DHA and 1.2 gram of EPA) every day for four weeks and found those who supplemented could be exposed to UV light for longer before experiencing skin redness. Another trial found taking 5 grams of fish oil twice a day for six months significantly increased the amount of UV exposure participants could handle before being burned, but the benefits seemed to disappear once they stopped supplementing. Plus, the safety of this high of a dose may be a concern. Some scientists believe supplementing with omega-3s may help suppress the inflammatory response that happens after exposure to ultraviolet radiation, but more research is needed.

Research suggests omega-3s also may help reduce signs of aging. A few cross-sectional studies found people with higher intakes of omega-3 fatty acids had less skin wrinkling on sun-exposed areas and were less likely to have dry skin and skin thinning.

Polyphenols

Some studies have found sun-protective benefits in both topically applied and ingested polyphenols. Polyphenols are powerful antioxidants found in plants, such as fruits and vegetables, whole grains and flowers. Many well-known sources include black and green tea, red wine and foods such as cocoa and dark chocolate, beans, soy, berries and artichokes.

In vitro and animal studies suggest polyphenols in green tea might have photoprotective benefits when ingested or applied topically. More human studies have been done on the benefits of topical green tea extract application, but some have tested the sun-protective benefits from ingesting green tea.

One study had participants (all females) drink a liter of green tea (containing 1,402 milligrams of green tea catechins) daily for 12 weeks and found it had skin-protective benefits after six weeks. Participants who drank the tea could be exposed to UV light longer before experiencing skin reddening. After 12 weeks, the benefits were even greater and included better skin elasticity and structure, reduced water loss from the skin, increased blood flow in the skin and higher serum flavonoid concentration. However, a separate study in which participants took capsules of 1,080 milligrams of green tea catechins per day for 12 weeks found no benefit.

In one study on cocoa powder, participants (all female) drank either a high (326 milligrams) or low (27 milligrams) flavanol-containing cocoa beverage every day for 12 weeks. At the end of the study, participants who consumed the high-flavanol drink saw less skin reddening when exposed to UV and had improved skin structure and circulation. Another study found consuming 6 milliliters of high-polyphenol wine per kilogram of body weight over 40 minutes helped protect skin against UVB. However, the study size was small with only 15 male participants, and the amount of wine needed to reproduce these benefits may not be practical. For instance, a 120-pound person would need to drink 11 ounces of wine in 40 minutes. For individuals who are of legal age and choose to drink, the 2020-2025 Dietary Guidelines for Americans suggests limiting alcohol intake and, for wine, this amounts to one, five-ounce glass or less a day for women and two, five-ounce glasses a day or less for men.

Coffee also may have sun-protective benefits. Researchers of one study examined food-frequency questionnaires of 447,357 non-Hispanic white people and found those who consumed four or more cups per day had a 20% lower risk of developing malignant melanoma after a 10-year follow-up compared to those who drank one or fewer cups. Interestingly, the benefits were not applicable to decaffeinated coffee. The Food and Drug Administration has stated that 400 milligrams of caffeine a day (or about four or five cups of coffee) is not generally associated with dangerous, negative effects for healthy adults who are not pregnant or breastfeeding.

For registered dietitian nutritionists

While more research is needed — especially research including a wider range of skin tones — current findings suggest some carotenoids, polyphenols and vitamins may help protect the skin from ultraviolet radiation from the inside out. For registered dietitian nutritionists seeing patients or clients with a heightened risk of skin cancer or who have patients or clients asking questions about overall skin health, it may be worthwhile to discuss the potential benefits of these compounds and encourage greater consumption from dietary sources or possibly supplementation. If supplementation is considered, other factors will need to be taken into account, since the doses of supplements described were high in some cases and/or may interact with medications. However, it is important to reiterate that the more certain ways to protect skin are by limiting exposure to sunlight and wearing sunscreen and sun-protective clothing.

References

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From hummus to baked goods to sushi, sesame is a prevalent and versatile ingredient found in foods around the world. Yet for individuals with a sesame allergy, consumption can be dangerous, with reactions ranging from mild to severe.

It is estimated that more than 1 million Americans have a sesame allergy. Yet, until recently, sesame was not considered to be one of the major food allergens in the United States. Therefore, labeling of sesame on packaged food products has not been required, making it challenging for those who have the allergy to identify foods made with sesame. The Food Allergy Safety, Treatment, Education and Research Act signed into law by President Biden on April 23 named sesame as the ninth major food allergen in the U.S., requiring it to be declared on food labels beginning January 1, 2023.

Allergen Legislation
The Food Allergen Labeling and Consumer Protection Act of 2004 recognized what became known as the “Top 8” major allergens: milk, wheat, soybean, eggs, fish, shellfish, peanuts and tree nuts. These allergens were believed to account for 90% of the food allergies in the United States. The law required disclosure on most packaged foods sold in the U.S., regardless of whether they were made in this country or imported.

Some foods and beverages are not covered by this legislation: meat, poultry and egg products, as they are regulated by the U.S. Department of Agriculture; alcoholic beverages, which are regulated by the Alcohol and Tobacco Tax and Trade Bureau; raw agricultural commodities such as fresh fruits and vegetables; and most foods sold without a label, such as in a restaurant.

Prior to the introduction of the FASTER Act in the U.S., labeling of sesame in food has been required in various parts of the world; Australia, New Zealand, Canada, EU, Iceland, Liechtenstein, North Macedonia, Norway, Switzerland, Taiwan, Turkey, Ukraine and GSO (Saudi Arabia, UAE, Kuwait, Bahrain, Oman, Qatar and Yemen) all require sesame labeling.

For years, consumers, advocacy groups and legislators have advocated for sesame to be added to the list of major allergens. In November 2020, the U.S. Food and Drug Administration published guidance for food manufacturers to voluntarily disclose sesame in their products. However, there still was no mandatory compliance or uniform oversight by the FDA. To change this, the FASTER Act of 2021 was introduced.

The FASTER Act will make it safer for those with a sesame allergy by requiring declaration of sesame on food labels. Additionally, it requires the U.S. Department of Health and Human Services to report on research opportunities for prevention, treatment and potential cures for food allergies. The FASTER Act also develops a scientific framework for adding additional allergens to the top nine in the future, if warranted.

While there is no clear data to indicate the introduction of a 10th major allergen in the U.S. anytime soon, some advocates are calling for clear labeling of substances such as corn, gluten, mustard and celery. In other regions of the world, labeling for these ingredients is sometimes required. More research is needed to identify the prevalence and severity of allergies to these ingredients in the U.S.

Sesame in Foods
According to Food Allergy Research & Education, sesame can be referred to by many names as an ingredient on a label, making it difficult for consumers to identify it in a product. Sesame may appear as benne, benne seed, benniseed, gingelly, gingelly oil, gomasio (sesame salt), halvah, sesame flour, sesame oil, sesame paste, sesame salt, sesame seed, sesamol, sesamum indicum, sesemolina, sim sim, tahini, tahina, tehina or til. It also may be hidden as “natural flavor” or “spices” in an ingredient statement.

Oils, such as peanut oil, that are derived from major allergens are often highly refined. This process removes the allergenic protein that causes an allergic reaction, making it safe for most people with that allergy. Sesame oil, however, typically is not highly refined, so the allergen is still present, making it unsafe for people who are allergic to sesame. Cold-pressed, expelled or extruded oils (sometimes referred to as gourmet oils) from any of the major allergens still contain the allergenic protein and should be avoided by people with that particular allergy.

Sesame in Non-Food Items
In addition to food, sesame can be found in items including cosmetics, medications, nutritional supplements, perfumes and pet foods. Typically, sesame is labeled with the scientific name Sesamum indicum on these items. People with a sesame allergy may experience a reaction from contact with these items. Except for dietary supplements, non-food items do not have the same labeling requirements and are not covered under FALCPA or the FASTER Act.

Prevalence, Severity and Treatment of Sesame Allergies
While the exact number of people with a sesame allergy is unknown, a cross-sectional study published in 2019 surveyed 51,819 U.S. households from October 1, 2015, through September 31, 2016, and estimated that more than 1.5 million children and adults — 0.49% of the U.S. population — may have a sesame allergy. However, further analysis indicated that only 0.23% met the criteria for a “convincing” IgE-mediated allergy based on self-reported symptoms, and 0.11% never experienced a reaction, despite being diagnosed with a sesame allergy by a physician.

Most respondents reported having more than one food allergy, particularly peanuts. In fact, more than 75% of those with a likely sesame allergy also reported an allergy to one or more of the other top eight allergens.

One theory for the rise in food allergies, particularly sesame in the U.S., points to the growth of global flavors such as tahini, hummus and spice blends. People who may not have previously consumed sesame may have been unaware of the allergy. As sesame becomes more ubiquitous in dishes across America, an increase in the number of reported allergies to it seems likely.

Allergic reactions to sesame can range from mild (hives) to severe (anaphylaxis or multiple organ system involvement). More than 37% of survey respondents reported having a severe reaction and more than 20% reported wheezing, fainting, dizziness or low blood pressure.

According to the individuals surveyed, hives were experienced more frequently with a sesame allergy. Gastrointestinal symptoms such as stomach pain, cramps, diarrhea, nausea or vomiting occurred less oftenin people with a sesame allergy compared to those who were allergic to one of the top eight allergens.

Treatment for sesame allergic reactions vary based on the severity of the reaction. In the same 2019 study, about one-third of participants reported use of an epinephrine autoinjector, a device that administers medicine to treat severe allergic reactions, at some point in their lifetime; nearly half reported antihistamine use; less than one-tenth reported use of an asthma inhaler, with slightly more reporting use of corticosteroids.

This study suggests a sesame allergy can be severe and identifies an opportunity for improved research, awareness, treatment and management of sesame allergy for people and the food and nutrition industry, as well as government regulation.

Putting It Into Practice for RDNs
To provide proper nutrition care and guidance, registered dietitian nutritionists should educate themselves on food allergens and allergies, as well as their potential impact on a patient’s or client’s lifestyle. Advise patients or clients who suspect they have a sesame allergy to seek a medical diagnosis. Oral food challenges are the gold standard for a food allergy diagnosis, but other evidence-based methods may be used, along with a comprehensive medical history. Self-diagnosed allergies and intolerances can lead to unnecessary dietary restrictions and inadequate nutrition.

For patients or clients with a known sesame allergy:

• Recommend they always carry an epinephrine auto-injection device in case of anaphylaxis.
• Clarify that compliance for the FASTER Act does not begin until January 1, 2023. In the interim, urge them to continue reading food labels, looking for other ingredient names for sesame and avoid ingesting foods with sesame or coming into contact with non-food items that may contain sesame.

References

Biden signs law that makes sesame the ninth major food allergen. The Washington Post website. Published April 23, 2021. Accessed May 14, 2021.
FDA Encourages Manufacturers to Clearly Declare All Uses of Sesame in Ingredient List on Food Labels. Food and Drug Administration website. Published November 10, 2020. Accessed May 14, 2021.
FDA Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA) page. Food and Drug Administration website. Accessed May 27, 2021.
Food Allergens – International Regulatory Chart. University of Nebraska-Lincoln website. Accessed May 12, 2021.
Food Allergies. Food and Drug Administration website. Accessed May 8, 2021.
Sesame Allergy Rates Are Increasing: Here’s What to Know. Healthline website. Published August 2, 2019. Accessed May 8, 2021.
Warren C, Chadha A, Sicherer S, et al. Prevalence and Severity of Sesame Allergy in the United States. JAMA Netw Open. 2019;2(8):e199144.

Depressive symptoms can include lack of motivation, fatigue, feelings of overwhelm and worthlessness or guilt, sadness or abnormal negative mood, the inability to feel pleasure, problems sleeping or sleeping too much and negative self-cognition. Depression is commonly treated with antidepressant medications and/or psychotherapy, though research shows physical activity and social support also can be helpful.

Depression has many potential causes including biochemical factors, such as neurotransmitter activity and the gut microbiome, genetics, social and environmental factors, and even personality. A complex condition, depression likely stems from multiple origins.

Research on Diet Quality and Depression
While a poor diet may be associated with risk of depression, studies are still assessing whether quality of diet causes depression or worsens existing symptoms. Dietary patterns that have been examined and are thought to influence risk of depression include those high in ultra-processed foods, saturated fat (including high-fat dairy or fried foods), processed meat, refined grains and added sugars including sugar-sweetened beverages.

In a study of 139 children and adolescents with MDD, researchers found those with MDD reported eating fewer healthful foods than those without MDD. The authors inferred that it’s possible MDD leads to a less healthful diet, but also that less healthful dietary behaviors may lead to more depressive symptoms.

Other studies have shown that dietary patterns with high consumption of less processed foods including fruits, vegetables, whole grains, legumes, nuts, seeds and fish are inversely associated with risk of depression. Eating patterns including vegetarian and vegan, Mediterranean, traditional Japanese and Nordic diet have been studied, with positive outcomes. An analysis of 4,349 adults’ self-reported health and 24-hour food recall data from the Korea National Health and Nutrition Examination Survey found reduced depression rates with increased consumption of fruits and vegetables. A review of 12,062 Taiwanese Buddhists found participants who followed a vegetarian dietary pattern had lower incidence of depressive disorders than non-vegetarians; however, contradictory findings also have been observed.

Researchers suspect the benefits of a healthful diet relative to depression risk could be attributed to factors including improvements in vascular health, lower levels of LDL cholesterol, lower inflammatory levels, less oxidative stress, improvements in neurotransmitters serotonin and norepinephrine or improvements in the gut microbiome.

Dietary Intervention
Preliminary research shows dietary intervention by a registered dietitian nutritionist may be helpful for people with depression. A 12-week randomized controlled trial of dietary improvement for 67 adults with major depression — which included either seven 60-minute sessions by a clinical RDN or social support in addition to dietary changes based on a modified Mediterranean diet model — found those who received dietary education support from an RDN experienced significantly greater improvement in depressive symptoms than the control group.

In this study, the dietary intervention pattern included whole grains, vegetables, fruit, legumes, low-fat unsweetened dairy products, raw unsalted nuts, fish and moderate lean red meat, chicken, eggs and olive oil. Additionally, participants were instructed to eat according to their hunger and to reduce consumption of refined cereal, fried food, fast food, processed meat and sugar-sweetened beverages. They also were instructed not to have more than two alcoholic drinks per day and, if they did drink alcohol, it should be red wine and consumed with meals. For those who completed the trial, more than 32% (10 participants) achieved remission of symptoms, compared to 8% (2 participants) in the control group.

Food Insecurity and Depressive Symptoms
Food insecurity can lead to inadequate intake of nutrients, which can affect mental health and depression and increase risk for chronic disease, especially among women in the United States. Studies also show that food access issues are linked to depression. One cross-sectional study of 372 older adults found those with food insecurity had less ability to care for themselves and, in turn, had higher depressive symptoms, as well as poorer diets.

Exploring Individual Nutrients
Although specific nutrients have been studied as treatment for MDD, research findings have been mixed and inconclusive. Some research suggests consuming more of certain nutrients such as B vitamins, magnesium, vitamin D, zinc and omega-3 fatty acids may help reduce depressive symptoms. However, research isn’t yet clear on whether individual nutrients may be able to reduce risk of depression or improve symptoms in people experiencing depression or anxiety. Most studies indicate that more research is needed.

B vitamins
A systematic review and meta-analysis of B-vitamin supplementation and its effects on depressive symptoms, anxiety and stress found that, while there may be a potential benefit to mood in people reporting high levels of stress, it was not beneficial for healthy people or those at risk of mood disorders. Researchers concluded that supplementation may benefit those who are at risk because of either poor nutrient status or stress. A large cross-sectional, population-based study using validated surveys to assess dietary intake of B vitamins and psychological health in Iranian adults found a beneficial effect from a higher intake of biotin and lower odds of anxiety, depression and stress, after adjusting for several confounding factors. An inverse relationship also was observed with vitamin B₆ and the risk of stress. While the results were promising and suggested other B vitamins also may have an influence, researchers stated randomized, controlled trials are needed for further study.

Omega-3s
Omega-3 fatty acids have been shown to upregulate neurogenesis, the process of new neuron development in adults, which can have a protective effect. An inverse relationship has been noted between eating more fish and lower risk of depression. Some studies have shown improvements in depressive symptoms with omega-3 fatty acid supplements, especially when used with antidepressant medications; other studies have found that any benefit may be small and not clinically significant. Natural Medicines database by TRC Healthcare lists eicosapentaenoic acid, or EPA, supplementation as possibly effective for those with MDD. However, it states that docosahexaenoic acid, or DHA, does not appear to improve any type of depression. In studies, 1 to 6 grams of omega-3 fatty acids EPA and DHA per day have been used, but the duration has varied from several weeks to months.

Vitamin D
Evidence suggests adequate vitamin D intake may help protect the brain from experiencing low dopamine and serotonin levels, which is why correcting vitamin D deficiency may be beneficial for those diagnosed with depression. While there is some evidence of an association between low levels of vitamin D and depression, the National Institutes of Health explains that results of vitamin D and depression research are based on observational studies rather than clinical trials — like many studies on diet as it relates to depression. The Natural Medicines database indicates there is insufficient evidence to rate vitamin D’s effectiveness in treating depression and that it doesn’t seem to help with prevention.

Zinc
Especially when combined with antidepressant medications, zinc supplementation has shown potential to be helpful, but more research is needed to better understand why. Higher consumption of zinc has been associated with a 28% lower risk of depression, and researchers indicate that it shows promise as an adjunct therapy. Studies have used 7 to 25 milligrams of zinc supplements daily for up to 12 weeks.

In general, while some of these nutrients show potential benefits, research findings are very mixed, and many benefits are seen when used with antidepressant medications.

Dietary Supplements and Herbals
In February, the U.S. Food and Drug Administration warned of 10 companies illegally selling dietary supplements that claimed to treat depression and other mental health disorders. The warning states that any dietary supplements that claim to cure, treat, prevent or mitigate depression are considered unapproved new drugs and are potentially harmful.

In studies, some herbal supplements have demonstrated positive effects on depressive symptoms, but each case has considerations ranging from lack of conclusive evidence to drug-nutrient interactions that should be taken seriously.

When compared to a placebo, St. John’s wort extract has shown positive effects on mood, reduced insomnia related to depression and decreased anxiety symptoms. Although clinical guidelines from the American College of Physicians and NIH both note that St. John’s wort can be equally effective — and better tolerated — as some antidepressant medications in the treatment of mild to moderate depression, there are many challenges and considerations. These include assessing standardization of supplement dosing and significant, even life-threatening, drug-nutrient interactions such as potentially major interactions with antidepressants, contraceptive drugs, certain immunosuppressant medications and moderate interactions with cytochrome P450 substrates.

A class of herbs used to help the body adjust to physical and psychological stressors, adaptogens such as rhodiola, saffron and ginseng, among others, have been studied in the treatment and management of depression. Studies show that adaptogens may help improve sleep, including insomnia; balance and decrease the release of stress hormones including cortisol; and lessen symptoms of mild to moderate depression. However, given the wide range of types of adaptogenic herbs, limited studies and potential for drug-nutrient interactions, RDNs should use caution with advising the use of adaptogenic herbs and should work with the patient’s or client’s health care team to assess whether adaptogens could be used as adjunctive therapy.

Sleep, Stress Reduction and Physical Activity
While nutrition may play a role in the prevention and treatment of depression, some lifestyle factors also can make a difference. Some studies show a connection between sleep and depression, especially with insomnia. Depression disorders are associated with both reduced sleep duration and quality.

One of the most consistent findings about depression is that stressful life events can predict its onset. The ways in which people think about or process stress, how they regulate their emotional response to stress and how their bodies physically respond to stress can make a difference in whether a person will become depressed and how severely.

Studies show a benefit from stress reduction techniques, specifically mindfulness-based stress reduction, or MBSR. This eight-week program utilizes mindfulness meditation and other strategies that have led to significant reductions in depressive symptoms in several populations.

According to a systematic review of eight meta-analyses, there is evidence that exercise may help decrease symptoms of depression in the general population, regardless of age. Both aerobic and resistance training appear to help reduce symptoms. For MDD treatment specifically, the most common exercise prescription for adults is 60 minutes of moderate-intensity activity three times per week over a period of 24 weeks. Some of the reasons this may be effective occur in the brain, in both the hippocampus and prefrontal cortex, where it can help benefit mental health. The 2018 Physical Activity Guidelines for Americans lists regular physical activity as having a positive effect on health, including brain health and conditions that affect cognition such as depression and anxiety.

Role of RDNs
Nutrition and dietetics practitioners can play a vital role for patients or clients with depression, including MDD, but they need to have proper training and multidisciplinary support for the complex needs of people with these conditions. RDNs can use the Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Mental Health and Addictions to build knowledge and expand their practice in these specialty areas.

Another resource from the Academy is the Guidance Regarding the Recommendation and Sale of Dietary Supplements. RDNs can educate patients or clients on the safety and efficacy of dietary supplements commonly used to help treat depression, as well as the potential for medications and supplements to interact with foods and nutrients. It is important for RDNs to work with the patient’s health care team to assess the best intervention for managing interactions. RDNs also can assess for potential nutrient deficiencies that could impact mental health and educate patients or clients on how to meet their nutrient needs through food.

In general, RDNs should take a holistic approach to supporting patients or clients experiencing depression. If and when possible, provide dietary education and emphasize the importance of physical activity, adequate sleep and stress reduction. Educate patients or clients about the connection between stress and depression and, when needed, refer them for individual or group therapy, counseling or MBSR support. Consider connections between food insecurity and a person’s ability to manage self-care, nutritional status and risk of depression. And screen for clinical malnutrition in anyone with a mental health condition.

References

Academy Comments to SAMHSA re Primary and Behavioral Health Care Integration Program. Academy of Nutrition and Dietetics website. Published June 13, 2016. Accessed May 31, 2021.
Bangratz M, Abdellah S, Berlin A, et al. A preliminary assessment of a combination of rhodiola and saffron in the management of mild–moderate depression. <em 2018;14:1821.
De Sousa R, Rocha-Dias I, de Oliveira L, et al. Molecular mechanisms of physical exercise on depression in the elderly: a systematic review. Mol. Biol. Rep. 2021;17:1-0.
Depression. National Institutes of Health website.Accessed May 31, 2021.
Docosahexaenoic acid. Natural Medicines Database website. Updated February 1, 2021. Accessed May 30, 2021.
Eicosapentaenoic acid. Natural Medicines Database website. Updated February 18, 2021. Accessed May 30, 2021.
FDA Warns 10 Companies for Illegally Selling Dietary Supplements Claiming to Treat Depression and Other Mental Health Disorders. U.S. Food & Drug Administration website. Published February 19, 2021. Accessed May 30, 2021.
Girard T, Russell K, Leyse-Wallace R. Academy of Nutrition and Dietetics: revised 2018 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in mental health and addictions. J Acad Nutr Diet. 2018;118(10):1975-86.
Guu T, Mischoulon D, Sarris J, et al. International Society for Nutritional Psychiatry Research practice guidelines for omega-3 fatty acids in the treatment of major depressive disorder. Psychother Psychosom. 2019;88(5):263-73.
Holben D, Marshall M. Position of the Academy of Nutrition and Dietetics: food insecurity in the United States. J Acad Nutr Diet. 2017;117(12):1991-2002.
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Huang Q, Liu H, Suzuki K, Ma S, Liu C. Linking what we eat to our mood: a review of diet, dietary antioxidants, and depression. Antioxidants. 2019;8(9):376.
Jacka N, O’Neil A, Opie R, et al. A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’trial). BMC Med. 2017;15(1):1-3.
Ju S, Park Y. Low fruit and vegetable intake is associated with depression among Korean adults in data from the 2014 Korea National Health and Nutrition Examination Survey. J Health Popul Nutr. 2019;38(1):1-0.
Jung S, Kim S, Bishop A, Hermann J. Poor Nutritional Status among Low-Income Older Adults: Examining the Interconnection between Self-Care Capacity, Food Insecurity, and Depression. J Acad Nutr Diet. 2019;119(10):1687-1694.
Konstantinos F, Heun R. The effects of Rhodiola Rosea supplementation on depression, anxiety and mood–A Systematic Review. Global Psychiatry. 2020;3(1):72-82.
Korczak J, Perruzza S, Chandrapalan M, et al. The association of diet and depression: an analysis of dietary measures in depressed, non-depressed, and healthy youth. Nutr. Neurosci. 2021;27:1-8.
LeMoult J. From Stress to Depression: Bringing Together Cognitive and Biological Science. Curr Dir Psychol Sci. 2020;29(6):592-8.
Liao L, He Y, Li L, et al. A preliminary review of studies on adaptogens: comparison of their bioactivity in TCM with that of ginseng-like herbs used worldwide. Am J Chin Med. 2018;13(1):1-2.
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Mahdavifar B, Hosseinzadeh M, Salehi-Abargouei A, Mirzaei M, Vafa M. Dietary intake of B vitamins and their association with depression, anxiety, and stress symptoms: A cross-sectional, population-based survey. J. Affect. Disord. 2021;288:92-8.
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Omega-3 Fatty Acids. National Center for Complementary and Integrative Health website. Updated March 26, 2021. Accessed May 30, 2021.
Opie R, O’Neil A, Jacka F, et al. A modified Mediterranean dietary intervention for adults with major depression: Dietary protocol and feasibility data from the SMILES trial. Nutr. Neurosci. 2018;21(7):487-501.
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Peregrin T. Guidance Regarding the Recommendation and Sale of Dietary Supplements. J Acad Nutr Diet. 2020;120(7):1216-9.
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Feeding and eating disorders such as avoidant/restrictive food intake disorder, or ARFID, can have several causes with serious consequences. Registered dietitian nutritionists — especially those working with pediatric patients or clients with eating disorders — should be aware of signs and symptoms of ARFID, considerations for treatment and with which health care professionals to collaborate and refer to for comprehensive care.

What Is ARFID?
ARFID occurs when there is a change in eating or feeding that makes it impossible for the person to meet their caloric and nutritional needs. A child with ARFID may not eat or drink enough calories or nutrients to grow normally, and adults may not eat or drink enough to maintain normal body functions. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, or DSM-5, this change in eating must be accompanied by one or more of the following: “significant weight loss (or failure to achieve expected weight gain or faltering growth in children), significant nutritional deficiency, dependence on enteral feeding or oral nutrition supplements or marked interference with psychosocial functioning.”

The DSM-5 also states ARFID cannot occur simultaneously with anorexia nervosa or bulimia nervosa, nor can it be better explained by an underlying medical condition or mental disorder. Additionally, it cannot be diagnosed if the condition is better attributed to food insecurity or religious practices.

Like anorexia nervosa, ARFID results in an avoidance of food; unlike anorexia nervosa, individuals with ARFID are not concerned with body shape or size. Rather, the disorder presents in three ways: a lack of interest in food or a low appetite (the restrictive subtype); cutting out certain foods due to sensory sensitivities (the aversion subtype); or a restricted intake caused by a traumatic event or fear of a traumatic event, such as choking or vomiting (the avoidant subtype).

Making a Diagnosis
Before the addition of ARFID to the DSM-5 in 2013, children with ARFID often were described by practitioners as having “Selective Eating Disorder” or were diagnosed with “Feeding Disorder in Infancy or Early Childhood.” Only children under 6 could be diagnosed with FDIEC, whereas there is no age limit when diagnosing ARFID. This change acknowledges that, while ARFID may be more common among children and teenagers, it can persist into adulthood if left untreated.

“ARFID is a fairly new diagnosis, which was added to the eating disorders section of the DSM-5,” says Anna Lutz, MPH, RD, LDN, CEDRD-S, co-creator of Sunny Side Up Nutrition and co-owner of Lutz, Alexander and Associates Nutrition Therapy in Raleigh, N.C. “Because of this addition, more and more individuals that meet the criteria for ARFID are now being treated at higher levels of care.”

People with autism spectrum conditions, attention deficit hyperactivity disorder and intellectual disabilities, as well as children with anxiety disorders and those who do not outgrow normal picky eating, are at a higher risk of developing ARFID. People of all ages and genders are at risk of developing ARFID, though it is more common in children and young people and is thought to be more common in males.

Typically, children with picky eating will still eat foods from all food groups and their pickiness does not interfere with their growth and development. Children with ARFID, however, may avoid eating entire food groups and their extreme picky eating can stunt growth and hinder weight gain. Usually, ARFID is accompanied by anxiety and worry around eating. The disorder can disrupt family dynamics and make eating around others distressing and anxiety-provoking.

Physical signs of ARFID include stomach cramps or other gastrointestinal pain, dizziness or fainting, fatigue and sleep disturbances, difficulty concentrating, amenorrhea and the propensity to get cold easily.

How to Treat ARFID
Like other eating disorders, when treating patients or clients who are diagnosed with ARFID, collaboration with health care professionals in a team approach is preferred. RDNs, psychotherapists, speech language pathologists, occupational therapists and physicians may be involved.

Lutz says that because ARFID is a newer diagnosis, more research is needed to determine best treatments. Therefore, there is no definitive way a practitioner should treat a patient or client with ARFID. While many current therapies mimic traditional eating disorder treatments such as residential care and family-based treatment, many practitioners, including Lutz, have found responsive feeding therapy, or RFT, to be helpful and hope more research will be dedicated to the subject.

Rather than trying to change the behavior of the child with ARFID (for instance, trying to get them to eat more food), RFT puts more emphasis on the relationship between the caregiver or parent and the child. “Responsive feeding therapy is a treatment that takes into account the feeding relationship between the caregiver and the individual — the connection between them and collaboration between them,” Lutz says.

According to Lutz, this approach empowers the caregiver and the child and encourages caregivers to listen to what their child is telling them about what they are or aren’t eating. “A good first step is for parents and caregivers to notice how they feel when they’re feeding. Since many feeding issues come from anxiety, if a caregiver is also feeling worried and experiencing anxiety, that can be a communication to the child.”

Self-reflection from the caregiver or parent can help facilitate a calmer eating environment, which, Lutz says, RDNs should encourage before addressing more logistical questions, such as which foods parents are serving their children.

Additionally, RDNs should determine which ARFID subtype is present, since each subtype may require a different approach. For instance, Lutz says treatment of a child with avoidant ARFID who is afraid to eat because of a traumatic event such as choking may require more coaching of the parent. “A parent may feel scared to push their child who had a choking incident, or the opposite — a parent forcing too much may feed into the anxiety. It usually requires a lot of coaching for the parent to take charge and reassure their child that they’re going to be OK.”

While a standardized approach to treating ARFID may be far off, RDNs can help progress the field by being aware of the warning signs, learning more about responsive feeding therapy, encouraging caregivers and parents and learning together with their fellow practitioners.

Learn more about various treatments and approaches for each subtype of ARFID, warning signs that may indicate a referral to a speech language pathologist and which treatments may be more harmful than helpful by watching the FNCE® 2020 session Picky, Selective, ARFID? Assessment and Treatment of Pediatric Feeding Difficulties.

References

Avoidant Restrictive Food Intake Disorder (ARFID). National Eating Disorder Association website. Accessed May 21, 2021.
Balla Kohn J. What Is ARFID? J Acad Nutr Diet. 2016;116(11):1872.
Interview with Anna Lutz, MPH, RD, LDN, CEDRD-S.
Lesser J. More than picky eating—7 things to know about ARFID. National Eating Disorder Association website. Accessed June 15, 2021.
Manikam R, Perman JA. Pediatric feeding disorders. J Clin Gastroenterol. 2000;30(1):34-46.
Picky, Selective, ARFID? Assessment and Treatment of Pediatric Feeding Difficulties. Food & Nutrition Conference & Expo^™ 2020 recorded session. Published October 21, 2020. Accessed May 21, 2021.
Responsive Feeding Therapy: Values and Practice. Responsive Feeding Therapy website. Published August 16, 2020. Accessed May 24, 2021.
Thomas J, Lawson E, Micali N, et al. Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Curr Psychiatry Rep. 2017;19(8):54.
What is ARFID? An Overview of the Often-Missed Eating Disorder. Central Coast Treatment Center website. Published October 2020. Accessed May 24, 2021.

Defining Placebo and Nocebo
The term placebo in health care dates to at least the late 1700s, when British physician William Cullen used the word to describe his administration of medications at a lower dose to patients with incurable disease. Cullen claimed he did this to please and provide comfort to his patients. Although there was no cure for their disease, he knew his patients expected a treatment and offering them medication provided satisfaction. Cullen employed what is now considered an “active placebo,” when a real drug is given at a sub-therapeutic dose.

In 1811, Hooper’s Medical Dictionary defined placebo as “any medicine adapted more to please than benefit the patient.” Today, Merriam-Webster defines placebo as “a usually pharmacologically inert preparation prescribed more for the mental relief of the patient than for its actual effect on a disorder.”

While a placebo generates positive effects, a nocebo does the contrary. According to Merriam-Webster, a nocebo is “a harmless substance or treatment that when taken by or administered to a patient is associated with harmful side effects or worsening of symptoms due to negative expectations or the psychological condition of the patient.”

Beyond a Pill
Talk of placebos may conjure images of sugar pills, but research suggests a pill isn’t the only thing inducing placebo effects. The very act of visiting a health care provider may be a form of placebo. The influence of the patient-provider relationship on health outcomes is considered “placebo-rapport,” or the placebo aspect of routine care when no therapeutic intervention is given. A therapeutic ritual or treatment, such as taking a pill at the same time each day as prescribed by a doctor, is considered “placebo-treatment.”

Many studies support the potential of placebo-treatment and placebo-rapport. One example is a randomized controlled trial of people with irritable bowel syndrome who were given acupuncture with dummy needles (placebo-treatment) and spent varied lengths of time with the practitioner (placebo-rapport). The group that spent the most time with the practitioner received a 45-minute initial consultation, during which the practitioner displayed “a warm, friendly manner” and employed “active listening (such as repeating the patient’s words, asking for clarifications); empathy (such as saying ‘I can understand how difficult IBS must be for you’); 20 seconds of thoughtful silence while feeling the pulse or pondering the treatment plan; and communication of confidence and positive expectation (‘I have had much positive experience treating IBS and look forward to demonstrating that acupuncture is a valuable treatment in this trial’).” Another group received a five-minute initial consultation where interaction with the practitioner was limited, and a third group received no treatment. of confidence and positive expectation (‘I have had much positive experience treating IBS and look forward to demonstrating that acupuncture is a valuable treatment in this trial’).” Another group received a five-minute initial consultation where interaction with the practitioner was limited, and a third group received no treatment.

After six weeks, the group with the highest level of interaction with a practitioner saw significantly greater results: a higher global improvement scale, higher adequate relief of symptoms, the largest declines in symptom severity score and the greatest increase in quality of life. The group that received the five-minute consultation reported better results (with the exception of quality of life) than the group that received no treatment at all.

Not only might the length of time spent with a practitioner impact health outcomes, but some studies suggest demeanor, words and attitude of a practitioner may have influence, noting poorer outcomes or nocebo effects in people whose doctor expressed doubt in a particular treatment or who had a negative demeanor.

Placebo-rapport also may enhance the efficacy of real drugs, not only placebos. For instance, one study found that when a pain medication was administered to patients without their knowledge, it had no effect. When the medication was administered again by a clinician with the patient’s knowledge, the drug was found to be more effective than placebo.

Ethics and Deception
The deception sometimes involved in using placebos — administering fake medications or providing a fake procedure without a patient’s knowledge or consent — has some wondering how ethical placebos in practice might be.

But recent studies have shown deception may not need to be a factor. For instance, a 2016 randomized controlled study examined the impact of “open-label placebos” — knowingly taking a placebo — on lower back pain. During this study, all participants were educated on placebo effects, including how powerful placebo effects can be, the potential impact of a positive attitude on inducing placebo effects and the importance of taking the placebo pills each day. Half of the participants took placebo pills, which were in a bottle labeled “placebo pills,” and the other half continued treatment as usual without taking placebo pills.

After three weeks, the open-label placebo group saw a significant reduction in pain and disability related to pain compared to the group who did not take the placebo pills. During interviews, some participants explained they experienced increased pain on a day when they forgot to take the placebo pills and one participant even said, “it worked so well that it has to contain something.”

A 2021 systematic review identified 11 studies involving open-label placebos and found significant positive effects of open-label placebos when compared to no treatment. The conditions identified as having positive results from openlabel placebos included seasonal allergies, IBS, chronic back pain, migraine, fatigue in cancer survivors, attention deficit hyperactivity disorder, menopause hot flashes and major depressive disorder.

Placebo Conditions
Placebos target symptoms — not diseases — particularly subjective or self-perceived symptoms. For example, a placebo will not cure cancer or shrink a tumor, but it might reduce a person’s perceived pain from radiation or nausea from chemotherapy. In general, placebos are shown to be most effective for psychological conditions and there are more studies showing promise for placebos in cases such as pain management, stress-related insomnia and cancer treatment side effects.

Mechanisms of Placebo
As research continues to test the possibilities of placebos, interest on exactly how placebos work is rising. Researchers believe the answers are in the brain.

To date, research suggests placebos work by activating specific areas of the brain involving autonomic responses, or involuntary bodily functions, such as heart rate, sweating or digestion; neuroendocrine responses, or fluctuations in hormones controlled by the hypothalamus–pituitary–hormone systems; and neurotransmitters such as cannabinoids, dopamine and opioids in the brain. Awareness of the person receiving the placebo has been a key factor in studies, showing a significantly reduced response to medications and placebos when an individual is unaware of its administration.

While many specifics concerning the biological processes of the placebo effect are still uncertain, it is evident that psychological factors play a role, including the beliefs and attitude of the person taking the placebo in addition to the context in which it is given, by whom it is given and the attitudes and beliefs of the administrator.

Implications for RDNs
It may be beneficial for registered dietitian nutritionists to make note of the influence of placebo-rapport and attempt to utilize its benefits. Authors of a 2019 paper provided a framework for employing placebo-rapport, stating the phenomenon can be broken down into two key factors: the patient’s or client’s belief that a practitioner (1) “gets it” and (2) “gets me,” meaning the practitioner demonstrates knowledge and competency but also displays genuine care, empathy and engagement.

Competency is further dissected into two factors: perceived competency as it relates to the specific patient or client — showing understanding of their family history, disease and treatment — and competency in general — the practitioner’s educational background, training and ability to confidently articulate concepts. The two-factor breakdown also is true for care and empathy. One factor is patient- and client-specific — taking interest in the patient’s or client’s life outside of a health care context, listening to their stories, understanding their values, practicing active listening and using their name — and then in general, being friendly to co-workers, smiling and engaging socially.

RDNs who work with patients or clients to help manage symptoms, such as those related to IBS or cancer treatments, may particularly benefit from the concept of placebo-rapport. By emulating behaviors of practitioners in placebo effect research, such as active listening, empathy and communication of confidence — behaviors also emphasized in motivational interviewing — RDNs can serve as a positive influence for their patients and clients, which may ultimately increase the success of their nutrition therapy and health outcomes.

References

APA Dictionary of Psychology: Autonomic nervous system (ANS). American Psychological Association website. Accessed March 29, 2021.
Carvalho C, Caetano J, Cunha L, et al. Open-label placebo treatment in chronic low back pain: a randomized controlled trial. Pain. 2016;157(12):2766-2772.
Finnis D. Chapter One – Placebo Effects: Historical and Modern Evaluation. Int Rev Neurobiol. 2018;139:1-27.
Howe L, Leibowitz K, Crum A. When Your Doctor “Gets It” and “Gets You”: The Critical Role of Competence and Warmth in the Patient-Provider Interaction. Front Psychiatry. 2019;10:475.
Kaptchuk T, Miller F. Placebo Effects in Medicine. N Engl J Med. 2015;373:8-9.
Kaptchuk T, Kelley J, Conboy L, et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ. 2008;336(7651):999-1003.
Nocebo. Merriam-Webster website. Accessed March 29, 2021.
Placebo. Merriam-Webster website. Accessed March 29, 2021.
Sussex R. Describing Placebo Phenomena in Medicine: A Linguistic Approach. Int Rev Neurobiol. 2018;139:49-83.
The power of the placebo effect. Harvard Health Publishing Harvard Medical School website. Updated August 9, 2019. Accessed March 29, 2021.
von Wernsdorff M, Loef M, Tuschen-Caffier B, et al. Effects of open-label placebos in clinical trials: a systematic review and meta-analysis. Sci Rep. 2021;11(3855).
Wager TD, Atlas LY. The neuroscience of placebo effects: connecting context, learning and health. Nat Rev Neurosci. 2015;16(7):403-418.

Taste perception (sensing the five taste qualities — salty, sweet, bitter, umami and sour) and olfaction (estimated to detect more than a trillion different odors) are a sensory duo. While our ability to smell plays a dominant role in food enjoyment, quality of life and nutrition-related health outcomes, smell impairments are often undiagnosed and have negative health consequences.

Sense of smell begins with orthonasal olfaction, when the nose detects odors. Upon chewing and swallowing food, odors and aromatic compounds are sensed via retronasal olfaction in the nasal cavities, tissues and nerves that send neurological signals to the olfactory bulb in the brain.

Olfactory Impairment and Prevalence
Sinus infections or inflamed mucus membranes can inhibit or limit flavor perception without disrupting taste receptors that perceive taste qualities such as sweet and salty.

The smell disorder hyposmia, meaning a reduced sense of smell, and parosmia, which causes distorted smells, have become more prominent as a reported COVID-19 symptom along with anosmia, the complete loss of smell. Prior estimates have been obtained through the National Health and Nutrition Examination Survey, which includes self-reported, subjective assessments and objective assessments, including tests of participants’ odor perception and taste function. The 2013-2014 NHANES results indicated that more than 12% of adults 40 and older had olfactory impairment, of whom 3% had complete loss of smell or a severely reduced sense of smell.

Men may experience more smell impairments, potentially double that of women, and most studies indicate significant declines in olfactory function with age.

Olfactory impairment is commonly underrepresented when people self-report or use subjective assessments, rather than objective assessments. For example, in a systematic review and meta-analysis of 175,073 people from 10 countries, olfactory impairment was 9.5% using self-reporting compared to 29% with objective assessments.

According to Danielle Reed, PhD, associate director of Monell Chemical Senses Center in Philadelphia, “the prevalence for COVID-19-related smell loss is [as of March 2021] 46% when the sense of smell is measured by self-report and 69% when measured objectively. This estimate is based on 202 studies done on 151,389 people.”

Quality of Life and Nutrition-related Health
The smell and taste impairments caused by COVID-19 raised awareness of chemosensory disorders, which have the potential to result in significant mental and physical health consequences and present as an invisible disability. “Emotional health and well-being, socialization and physical conditions may interplay with chemosensory perceptions and affect what people think, choose and ultimately eat or drink,” says Jacqueline B. Marcus, MS, RDN, LDN, FADA, FAND, author of Aging, Nutrition and Taste (Elsevier, 2019) and founder of TasteOverTime.com.

The olfactory bulb is connected to the limbic system, which is involved in memory, emotion and learning, explaining why specific odors can evoke emotional responses, influence behavior and trigger memories of long-forgotten events of childhood pastimes, family meals and celebrations. People with anosmia and smell impairments often report feelings of isolation, anger, apathy and depression and a disconnect from people who aren’t aware of the impact of loss of smell. Marcus adds that “this ‘perfect storm’ may result in decreased interest in food consumption, adequate nutrition or compromised health. Sometimes isolation may be the turning point.”

Nutrition-related health issues can develop from smell impairment and, over time, may result in weight changes, malnutrition and nutrient deficiencies, particularly among elderly populations. The issue isn’t easily resolved by simply promoting nutrient-rich foods. “Overall, people who lose their sense of smell may avoid eating because it is not enjoyable and they may be malnourished or lose weight,” says Reed. “But some people, especially those with a partial sense of smell, may overeat to compensate for the loss of smell, for example, salty chips or sweet ice cream.”

Based on preliminary research, inadequate nutrition can also lead to further nutrient deficiencies of which minerals zinc, copper and magnesium as well as vitamins A, E, B₁₂ and D may cause or exacerbate smell and taste impairments.

Health-related Smell Impairment
Most common: Head trauma, nasal polyps, allergic rhinitis and upper respiratory infections are leading causes of impaired olfaction. Respiratory infections from bacteria or viruses often resolve without serious threats to health; however, COVID-19 increased awareness that sensory changes can signal a potentially deadly virus and become more predictive of infection than other common COVID-19 symptoms.

Neurological: Alterations in smell also may be early symptoms of neurological diseases such as multiple sclerosis, Alzheimer’s disease and Parkinson’s disease, in which a decline in sense of smell may signal the condition several years before a diagnosis or primary symptoms develop. Multiple studies indicate 85% to 90% of patients with Alzheimer’s experience smell impairment and 45% to 96% of those with Parkinson’s disease do as well.

Diabetes: A large meta-analysis indicated olfactory impairment in people with diabetes was 1.58 times the control group and associated with both Type 1 and Type 2 diabetes. The impact of hyperglycemia and diabetic neuropathy on the olfactory nerve was proposed as a central mechanism of sensory decline. For adults 40 and older with diabetes, the 2013-2014 NHANES data indicated a significant trend in severe anosmia or severe hyposmia for people on oral and insulin treatment, but no association was observed between the duration of diabetes and the prevalence of olfactory dysfunction.

Cancer: Between 70% to 77% of cancer patients experienced taste alterations during some types of chemotherapy. In a review of 11 articles, reduced perception of sweet was associated with malnutrition and undernutrition. However, the impact of cancer treatment on olfactory function is understudied and studies of taste alterations of patients mostly rely on self-reports without pre-treatment chemosensory assessment.

Medications: Half of the top 100 prescription medications used in 2017 elicited taste or smell complaints or disorders. In a review of clinical trials, more than 350 medications were associated with taste alterations and more than 70 with olfactory effects. The incidence of adverse chemosensory effect on average was 5% across most medications but ranged as high as 66% for an insomnia drug; however, researchers noted limitations of self-reported data. A primary concern expressed in the research was the impact on reduced medication compliance for patients experiencing taste and olfactory side effects.

Assessment
Multiple studies mention the limitations of self-reported taste and olfactory symptoms and risks of undiagnosed patients. Reed believes smell and taste assessments should be part of routine clinical care and suggests practitioners “consider using new quick tests, especially for the sense of smell.”

In 2013, a continuing medical education article in the American Family Physician journal recognized that patients don’t often notice or differentiate between losses of smell or taste and recommended physicians become more familiar with symptoms, pre-clinical signs of serious conditions and consider using standardized questionnaires, office-friendly smell disorder tests and referring to otolaryngologists or smell and taste centers.

Marcus suggests that because people may be unaware of chemosensory changes, nutrition and health professionals can potentially flag nutrient and health issues by asking unobtrusive questions about basic perceptions of taste and smell.

Food Preparation and Culinary Nutrition
The sense of smell is an effective warning system for gas leaks, fire and toxic fumes, yet it fails as a reliable indicator of rotten foods; the olfactory senses cannot detect pathogenic bacteria. It’s important to teach people with chemosensory impairment to store foods properly and notice discoloration and texture changes in foods.

Chemosensory impairment often reduces appetite and interest in eating. Experiencing an appetite is key to both food enjoyment and sufficient intake of calories; however, promoting ways to build an appetite can be negatively associated with overeating. “The topic of appetite and weight is touchy,” Marcus says. “If foods and beverages look good and smell great, people may eat more, and the reverse may also be the case. Improving the appearance and texture of food and enhancing aromas may arouse appetite. But there are so many other factors that contribute to weight gain, other than the ingestion of tasty and aromatic foods and beverages.”

Depending on the level and type of chemosensory impairment, culinary skills that may help increase interest in eating include:

TASTE QUALITIES: Highlight favorite tastes that are perceived. If sour is sensed and appreciated, create sour marinades, sauces or dressings.

PHYSICAL SENSATIONS: Create textures based on preferences such as grain berries for bouncy, al dente texture, crunchy nuts or crisp vegetables for contrast and pungent spices or condiments, as desired.

HEIGHTEN FLAVORS: Use salt to enhance natural flavors or ingredients such as MSG to boost savory, umami flavors without increasing sodium.

Smell Disorder Resources

Want more info? These resources include support options and practical details for professionals:

• abScent Community Support
• Fifth Sense Community Support
• Monell Center Resources and COVID-19
• National Institutes of Health: NIDCD: Smell Disorders

References

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Chan J, García-Esquinas E, Ko O, et al. The Association Between Diabetes and Olfactory Function in Adults. Chemical Senses, 2018; 43(1):59–64.
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For years, the number-one driving factor behind consumer food choices has been taste. However, over time, value-driven consumers are weighing additional considerations, including social justice, animal welfare and environmental stewardship — all which influence their food and beverage purchasing habits. As awareness and action continue to evolve, the idea of “ethical eating” is becoming increasingly more mainstream.

“Ethical eating” refers to the consideration of the economic, social and environmental impacts of purchasing or consuming foods and beverages.

The role of ethics has become increasingly prioritized for both the food and agriculture industry and the value-driven consumer. While there have been significant improvements in animal welfare, social justice and environmental stewardship, further opportunities exist. Industry and consumers can work together to make progress toward a more sustainable and ethical supply chain.

Social Justice
For many, protecting and supporting workers’ rights is of utmost importance. Issues such as equal pay, gender equality, diversity and inclusion, forced labor, child labor and more are complex considerations.

Labor Practices
Approximately 15% of the food eaten in the United States is grown or produced internationally. Many commodities including coffee, bananas, chocolate and avocados — native to regions in Mexico, Central America and South America — are imported to the U.S. in large quantities. Seafood eaten in the U.S. is primarily imported from China, Thailand, Canada, Indonesia, Vietnam and Ecuador.

While importing foods can support international relations and help bring steady income to small farmers and growers overseas, it also means that some relevant regulation often falls outside of U.S. jurisdiction. Challenges associated with imported foods include less-robust labor standards and enforcement than what is generally found in the U.S. Violence, forced labor and extortion have been observed, as individuals and groups compete for commodities and their associated profits.

For example, the seafood industry has been under scrutiny for human rights abuse in the supply chain, primarily driven by the presence of forced labor. According to a 2018 report from the USDA’s Foreign Agricultural Service, “Thailand has been listed as a country with prevailing problem of human trafficking and illegal, unregulated, and unreported fishing (IUU).” Pressure from other countries, including the United States, has limited some of their fishing activity and measures, along with increased awareness of IUU in Asia-Pacific countries, have been implemented by agencies in conjunction with the Food and Agriculture Organization of the United Nations.

For U.S. companies that source seafood from international locations, transparency throughout the entire supply chain can be a challenge, in part because many ships and vessels rely on third parties for labor recruitment. In many regions, these third-party agencies may be unregulated, and minimal monitoring and documentation may be required for the agencies and recruited employees. This limits transparency into labor and recruitment practices like worker’s contracts, compensation structure and working hours. Many recruited employees are migrants from other regions and are vulnerable to exploitation through poor wages and working conditions, for example. In some instances, human trafficking has been observed. In other instances, employees enter into work voluntarily and circumstances evolve into a forced labor situation.

Activists have called for policy reform to protect workers’ rights and increase transparency throughout the supply chain. Efforts have included the adoption of an international treaty, observance of the “International Day for the Fight against IUU Fishing” (June 5), and a joint statement by the FAO, International Labour Organization and the International Organization for Migration. Additionally, Thailand’s government has committed to complying with IUU regulations and established a fishery monitoring and surveillance system, including framework to prevent the exploitation of labor.

Other examples are coffee and cocoa used to make chocolate: Some have a robust Fairtrade certification system in place, while others do not. Buying Fairtrade means the product meets environmental, economic and social standards that support and protect farmers and their communities from injustices, such as unfair wages, while also protecting the environment. However, these standards are not without criticisms. Arguments against Fairtrade certifications contend that certification results in uneven economic advantages for coffee growers, for example, and lower-quality products for consumers. Alternatively, some experts think developing a Fairtrade certification system for other commodities may help protect farmers and growers, but the development of such a system would require significant time and resources.

Equity, Diversity and Inclusion
Equity, diversity and inclusion are key priorities in the food supply chain for companies, consumers and legislators. In 2020, as social justice issues in the United States came to the forefront of national news, the COVID-19 pandemic caused hunger and food insecurity to skyrocket, particularly in Black and Latino households. Many companies introduced programs to support a diverse, equitable and inclusive workplace for all people. These efforts do not go unnoticed, as consumers seek purpose-driven companies and products and make purchasing decisions aligned with their beliefs and values. In January 2021, the Biden administration implemented policies to address hunger and food insecurity in the U.S. that focus on a more equitable, diverse and inclusive food supply chain in the future.

Animal Welfare
Humane Treatment of Animals
Many stakeholders — government entities, commodity groups, third-party certifying bodies, special interest groups and others — set standards for the humane treatment of animals in the food supply chain, including those intended for food production and labor.

The Five Freedoms of Animal Welfare, originally developed by the U.K. Farm Animal Welfare Committee (now the Animal Welfare Committee), is a globally accepted framework for standard of care used for animals raised for food production. This framework is often used as a baseline for commodities including poultry, cattle and more; commodity-specific standards are then added to this framework, as appropriate.

Despite regulations and documentation standards for using animal raising claims on meat and poultry products, claims and labels associated with animal welfare standards can lead to consumer confusion. For example, a host of claims designate the degree of freedom a hen experienced before laying eggs. Claims on an egg carton include cage-free, free-range and pastured. For U.S. Department of Agriculture-graded eggs, “cage-free” indicates, among other criteria, that the hen was able to walk around the hen house before laying the egg. “Free-range” signifies the eggs come from cage-free hens that were allowed outside (sometimes in a fenced-in space). “Pastured” or “pasture-raised,” while not defined by the USDA, typically means eggs come from hens that had the ability to roam free on natural pastures. The term “pastured” eggs may sound like the most humane and ethical treatment, but more freedom means exposure to outside elements, sources of infection and violent interactions with other hens.

Antibiotics
Use of antibiotics in animals that are raised for food is a topic of growing interest, including concern for the humane treatment of animals and implications on human health after eating animals that were treated with antibiotics.

Antibiotics are used to treat sick animals as needed. By the time of slaughter, antibiotics have left the animal’s system, meaning it is technically “free of antibiotics.” The use of antibiotics in food production in the U.S. is monitored by the Food and Drug Administration to ensure humane and ethical treatment of animals.

Concern arises if the animal develops a level of resistance to antibiotics, especially daily use or mass fed antibiotics. That resistance can be transferred to humans through animal food products, as well as run-off into soil, water, crops and other elements. If a person needs the same antibiotic for their own health, they may have resistant bacteria. Many food organizations have adopted policies and commitments that include veterinarians’ oversight of antibiotic distribution and reducing or eliminating the use of antibiotics in animals that are important to human medicine, as outlined by the World Health Organization.

Environmental Stewardship
Climate change and deforestation are two key factors in environmental sustainability or stewardship. Climate change refers to long-term changes to Earth’s usual weather patterns, while deforestation refers to the loss or reduction of forest land for production across several industries. Deforestation has a compounding effect because it also contributes to climate change by reducing forest land that would otherwise keep excess carbon out of the atmosphere.

Efforts to combat climate change and deforestation and promote good forest stewardship focus on priority supply chains for products including palm oil, soy, beef and paper, to name a few.

Palm Oil
Palm oil is the world’s most common vegetable oil, naturally trans-fat free and extremely versatile in both the food system and other industries including cosmetics and biofuels. But its effect on the food system is complicated and largely misunderstood.

Because palm is a tropical crop grown in specific conditions, sourcing is limited to designated regions near the equator. As demand for palm oil continues to rise, especially after the FDA determined in 2015 that artificial trans fats (partially hydrogenated oils) were no longer “Generally Recognized as Safe,” clearing land for production has resulted in destruction of habitats for endangered species such as orangutans, as well as loss of biodiversity.

The production of palm oil is more efficient than soybean oil, its closest alternative, requiring significantly less land to produce the same yield. Additionally, palm oil is an important part of emerging economies and the livelihood of small farmers. When considering factors like cost, versatility, nutrition profile, land use and small farmer support, there is not a clear ethical alternative to palm oil.

Instead of replacing palm oil entirely, an alternative approach is to improve its sustainability. The Roundtable for Sustainable Palm Oil, or RSPO, is a nonprofit focused on developing and implementing sustainable palm oil practices globally. Different levels of RSPO-certified palm indicate the degree of environmental and social sustainability of the products. According to RSPO, purchasing products made with sustainable palm oil is an ethical solution that can help support smallholder farmers and encourage more organizations to improve the sustainability of their supply.

Soy
Like palm, soy is a common ingredient throughout the world. In fact, soy is the globe’s primary source of protein. It also is rich in essential amino acids, making it an accessible and useful ingredient. In addition to cooking, soy is widely used as feed for livestock that later becomes human food.

While U.S.-grown soybeans are certified sustainable, soy has been associated with deforestation in certain regions of the world. Significant amounts of natural resources such as water must be used in soy production. Efforts to improve supply include developing sustainable production practices and encouraging biodiversity.

Beef
Because cattle expel methane both from their mouth and as flatulence, greenhouse gases in livestock food production continue to be a key priority in sustainability efforts. However, significant improvements have been made to reduce the environmental impact of cattle. Advancements in production methods and technology have led to decreased food waste and increased efficiencies that mean fewer cattle can produce a greater volume of food.

While beef may be part of a largely sustainable supply chain in the U.S., that is not the case elsewhere. In Brazil and other regions where forests are converted to pastures to raise cattle for slaughter, tropical deforestation has been tied to beef.

Plant-based Options
According to the 2020 Food and Health Survey by the International Food Information Council, there has been an increase in consumption of protein from plant sources and plant-based meat and dairy alternatives over the past year. This trend may be due, at least in part, to people trying to reduce their carbon footprint. This is a heavily debated topic, with some arguing that a plant-based lifestyle is the best approach for the planet; others advocate for a lifestyle that incorporates both plant-based options and sustainably sourced animal-based foods.

Paper
Paper-based packaging is common in the food industry. Yet, as more restaurants transitioned to off-premise dining due to COVID-19, packaging use increased in importance. Paper can have a direct impact on deforestation if forests are not responsibly managed. Recycling is another key component to ensure a sustainable and ethical paper supply chain.

Paper can have a direct impact on deforestation if forests are not responsibly managed. Recycling is another key component to ensure a sustainable and ethical paper supply chain.

What the Food and Agriculture Industry Is Doing
Making Improvements. Restaurants and retailers are identifying animal welfare, environmental stewardship and human justice opportunities and are making improvements. They are working with suppliers, activist groups and other third-party experts to understand the intricacies of ethical eating from all angles and make the most responsible choice. Companies are making commitments and setting science-based targets, or SBTs, to reduce or eliminate their contribution to deforestation by shifting sourcing or adopting more sustainable practices. The USDA encourages and supports activities through its Sustainable Agriculture Program.

Being Transparent. Transparency is a key factor at the intersection of food and ethics. Companies are sharing lifecycle assessments, traceability reports and scorecards completed by third-party organizations that rate how they are doing on some of these important matters. Through corporate citizenship reports, large chains and small independent companies are describing how they are tracking and making progress. Corporate citizenship reports typically are available online for the public.

What You Can Do
Educate yourself for your patients or clients. Food choices are personal, as are the values driving those choices. When working with patients or clients who are interested in discussing economic, social and environmental considerations for food choices, it can be helpful to have a base knowledge of these concepts. Resources may include available information from restaurants and brands, including lifecycle assessments and corporate citizenship reports; third-party standards and scorecards that evaluate brand progress; information from the Academy of Nutrition and Dietetics, including the “Revised 2020 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems” and the robust list of Diversity and Inclusion resources; and resources from the Academy Foundation, such as the “Future of Food” initiative. If your patients and clients ask for information, provide credible resources to help them make informed decisions that work for them.

As a buyer, advocate for your values with your purchasing power. Not everyone has the same level of access to a variety of foods, particularly where selection is limited. Advocate for equity and the development of policies that support access to nutritious foods for all communities. Your personal advocacy might include buying products that align with your values and promote biodiversity; supporting less-familiar markets; or seeking out other varieties of foods to help keep unique, lesser-known varieties alive and support small farmers in various regions. If your local market does not carry specific foods you’re seeking, consider requesting it either in person or online through the “contact us” page of the grocer’s website.

This is an overview of ethical eating, but it isn’t all-inclusive. We want to hear from you! What value-driven considerations contribute to your food choices? Tell us on social media using #foodnutrimag or email us at foodandnutrition@eatright.org.

References

2020 Food and Health Survey. Food Insight website. Published June 9, 2020. Accessed January 15, 2021.
8 things to know about palm oil. WWF website. Published January 17, 2020. Accessed January 10, 2021.
Barnes A. Eggstra! Eggstra! Learn All About Them. U.S. Department of Agriculture website. Updated February 21, 2017. Accessed January 18, 2021.
Beef: Overview. WWF website. Accessed April 12, 2021.
Commodities and Products. USDA Foreign Agriculture Service website. Accessed April 12, 2021.
Fact Sheet: President Biden to Take Action to Advance Racial Equity and Support Underserved Communities. The White House website. Published January 26, 2021. Accessed April 12, 2021.
Fairtrade Standards. Fairtrade America website. Accessed January 10, 2021.
FoodBytes. Datassential website. Accessed January 10, 2021.
Forest Conversion. WWF website. Accessed January 10, 2021.
Global vegetable oil production set to reach new peak. Bio-based News website. Published October 15, 2018. Accessed January 10, 2021.
Global Wild Fisheries. Fish Watch U.S. Seafood Facts website. Accessed April 12, 2021.
Grannan C. What’s the Difference Between Morality and Ethics? Encyclopedia Britannica website. Accessed January 16, 2021.
Hidden Chains: Rights Abuses and Forced Labor in Thailand’s Fishing Industry. Human Rights Watch website. Published January 23, 2018. Accessed April 12, 2021.
Joint Statement on the International Day for the Fight against IUU Fishing. Food and Agriculture Organization of the United Nations website. Published June 5, 2019. Accessed April 12, 2021.
Labeling Guideline on Documentation Needed to Substantiate Animal Raising Claims for Label Submissions (2019). USDA Food Safety and Inspection website. Published December 2019. Accessed April 12, 2021.
O’Dowd P, Hagan A. Why Avocados Attract Interest of Mexican Drug Cartels. WBUR website. Published February 7, 2020. Accessed January 10, 2021.
Palm Oil. WWF website. Accessed January 10, 2021.
Rahmanulloh A. Biofuels Annual. USDA website. Published August 3, 2020. Accessed January 20, 2021.
Roundtable on Sustainable Palm Oil website. Accessed January 10, 2021.
Shaftel H. Overview: Weather, Global Warming and Climate Change. NASA Climate Change: Vital Signs of the Planet website. Accessed January 24, 2021.
Smart land use: Palm oil is the world’s most efficient oil crop. Malaysian Palm Oil website. Published November 12, 2020. Accessed April 12, 2021.
Soy. WWF website. Accessed January 10, 2021.
Sustainable Soybean Production. Soybean Connection website. Accessed April 12, 2021.
Thailand. USDA Foreign Agricultural Service website. Published May 8, 2018. Accessed April 12, 2021.
The biggest misunderstandings about palm oil. New Hope Network website. Published February 20, 2019. Accessed April 12, 2021.
The Five Freedoms for Animals. Animal Humane Society website. Accessed April 12, 2021.
The Problem with Fair Trade Coffee. Stanford Social Innovation Review website. Accessed January 10, 2021.
Tracking the COVID-19 Recession’s Effects on Food, Housing, and Employment Hardships. Center on Budget and Policy Priorities website. Updated April 8, 2021. Accessed April 12, 2021.
Trans Fat. U.S. Food and Drug Administration website. Accessed April 12, 2021.
UN’s Food and Agriculture Organization to mark International Day to Fight against IUU Fishing in Asia-Pacific (Bangkok event). Food and Agriculture Organization of the United Nations website. Published June 5, 2019. Accessed April 12, 2021.
WHO list of critically important antimicrobials (WHO CIA list). World Health Organization website. Updated May 8, 2019. Accessed January 24, 2021.

Since their debut four decades ago, the Dietary Guidelines for Americans have experienced quite the evolution. It might seem as if the 2020-2025 Dietary Guidelines, released in December 2020, are more of the same compared to their recent predecessors, but there are some significant changes to both the ninth edition as well as the procedures behind the scenes.

Enhanced Transparency
To promote transparency, some notable changes were made to the process of developing the 2020-2025 Dietary Guidelines for Americans and selecting the Dietary Guidelines Advisory Committee. For the first time, the U.S. Departments of Agriculture and Health and Human Services were responsible for selecting topics and scientific questions to be considered by the Committee before the Committee was established.

Furthermore, the agencies allowed for public comment on the topics and scientific questions before the Committee was selected. This change not only supported transparency, but also helped ensure the most appropriate Committee members were selected — members whose expertise matched the topics.

When the USDA and HHS issued a public request for Committee nominations, they also provided an outline of specific information needed in all nomination packages — another first. To better avoid conflicts of interest, everyone under final consideration for the Committee was required to submit a Confidential Financial Disclosure Report before being selected. Previously, this report was submitted after Committee members were already selected.

For the first time, the Committee had a sixth meeting, which was added to focus solely on reviewing the draft report. According to Jackie Haven, deputy administrator of the USDA Food and Nutrition Services’ Center for Nutrition Policy and Promotion, this allowed the Committee to discuss overarching findings and the draft of their scientific report, which previous Committees had not done.

Additionally, the Committee was required to explain how it planned to answer each scientific question — by conducting a systematic review using data analyses, food pattern modeling analyses or the USDA’s Nutrition Evidence Systematic Review — and post it online for public viewing and comment.

Of the six Committee meetings (all open for public viewing and some for in-person attendance), the public had two opportunities to provide oral comments rather than just one. And for the first time in two decades, a meeting was held outside of the Washington, D.C., metro area.

According to the Dietary Guidelines website, these changes were an effort to “promote a deliberate and transparent process, better define the expertise needed on the Committee and ensure the scientific review conducted by the Committee would address Federal nutrition policy and program needs.”

Life Stages
A highly anticipated update to the 2020-2025 Dietary Guidelines for Americans is the addition, or reorganization, of information into life stages. The life stages are organized into infants and toddlers (birth through 23 months); children and adolescents (ages 2 through 18, further broken down into groups of ages 2 through 4, 5 through 8, 9 through 13 and 14 through 18); adults (ages 19 through 59); women who are pregnant or lactating; and older adults (ages 60 and older).

The structural change complements a few overarching guidelines and themes: “Follow a healthy dietary pattern at every life stage,” and, “It is never too early or too late to eat healthy.” Haven explains that organizing the Dietary Guidelines by life stage allowed for more tailored guidance specific to each stage of life and showcased how healthy dietary patterns can be carried forward into the next life stage.

New Populations
Thanks to the Agricultural Act of 2014, guidance for infants and toddlers ages 0 to age 24 months and women who are pregnant or lactating are now included in the ninth edition of the Dietary Guidelines.

Guidelines for infants and toddlers address factors such as when to introduce complementary foods and potentially allergenic foods, how to determine developmental readiness for eating solid foods, and vitamins and minerals of concern. The newly added guidance for women who are pregnant or lactating includes information such as working with a health care provider to achieve weight management goals and special nutrient needs such as increased folate, iodine and iron.

An Emphasis on Culture, Budget and Preference
In every chapter, the guidelines focus on food groups and subgroups rather than specific foods, reiterating that the Dietary Guidelines are not prescriptive, but rather an outline or framework. This links to another key recommendation or overarching guideline: “Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions and budgetary considerations.”

“As our society grows and evolves, so too does our knowledge about the importance of representation and equity,” Haven says. “In the 2020-2025 Dietary Guidelines for Americans, we wanted to be crystal clear about the importance of celebrating the rich diversity of the people who live here and respecting cultural foodways.”

A broad spectrum of food examples is included in the guidelines to fit diverse preferences. For instance, taro leaves are an example of dark green vegetables, calabaza is listed for red and orange vegetables and cassava and plantains for starchy vegetables. Haven says the USDA and HHS made a concerted effort to represent all Americans through careful consideration of the food examples and images selected, showcasing the diversity of food and people through representation in age, life stage, race, ethnicity, body size and ability.

A Change in Name

The vegetable subgroup known as “legumes” is now called, “beans, peas and lentils.” While the foods in the subgroup have not changed, the USDA and HHS say the name is a more accurate description of the foods within the group.

Nutrient Density and Dietary Patterns
A noticeable emphasis of the 2020-2025 Dietary Guidelines for Americans is their reiteration of choosing nutrient-dense foods and focusing on dietary patterns — how someone regularly eats overall, not just a single meal. These are not new concepts to the Dietary Guidelines, but their presence appears more pronounced.

The guidelines state people should strive to achieve healthy dietary patterns that focus on nutrient-dense foods — foods that provide vitamins, minerals and other health-promoting components with little or no added sugars, saturated fat and sodium — to reduce the risk of chronic disease at every life stage.

The Dietary Guidelines also make prominent the percentage of total calories that should come from nutrient-dense foods versus the percentage that might come from other sources, such as foods and beverages that include sources of added sugars and saturated fats. The Dietary Guidelines state 85 percent of total calories should come from nutrient-dense foods to healthfully meet food group recommendations.

“With the limits on added sugars and saturated fat, it is important to underscore that there is not a lot of room for extras,” Haven says. “The majority of the foods people eat should be in nutrient-dense forms to help them meet their nutrient needs without consuming excess calories. For this reason, nutrient-density is a foundational piece of this edition and emphasized throughout each chapter.”

Controversy?
The 2020 Dietary Guidelines Advisory Committee recommended the 2020-2025 Dietary Guidelines for Americans set the limit of added sugars to 6 percent of total calories — a 4-percent drop from the previous guidelines. Essentially, the Committee concluded that if 85 percent of total calories came from nutrient-dense foods and the remaining 15 percent came from solid fats and added sugars, then added sugars should be limited to 6 percent or less to stay within the recommended total calories. The Committee also recommended limiting alcoholic beverages for both men and women who choose to drink to no more than one drink per day on days when alcohol is consumed. Like its predecessor, the 2020-2025 Dietary Guidelines for Americans specify that on days when alcohol is consumed, adults of legal age who choose to drink (and it is not contraindicated, such as during pregnancy) should limit consumption to two drinks or less per day for men and one drink or less per day for women. Ultimately, the USDA and HHS did not adopt the recommendations of the Committee, stating in a report that “there was not a preponderance of evidence in the Committee’s review of studies since the 2015-2020 edition to substantiate changes to the quantitative limits for either added sugars or alcohol.” The full response is available here.

Put It Into Practice
Registered dietitian nutritionists should become familiar with the 2020-2025 Dietary Guidelines for Americans to best counsel patients or clients and adequately answer questions. For a quick overview, the USDA offers the Top 10 Things You Need to Know About the Dietary Guidelines for Americans, 2020-2025. Additionally, RDNs can recommend patients or clients visit MyPlate.gov to take advantage of newly released features such as the new MyPlate quiz and personalized plans. The Dietary Guidelines website also includes additional resources for health professionals.

References

Dietary Guidelines Advisory Committee. Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. Dietary Guidelines website. Accessed January 22, 2021.
The Process to Develop the Dietary Guidelines for Americans, 2020-2025. Dietary Guidelines website. Accessed January 22, 2021.
Top 10 Things You Need to Know About the Dietary Guidelines for Americans, 2020-2025. Dietary Guidelines website. Accessed January 22, 2021.
USDA-HHS Response to the National Academies of Sciences, Engineering, and Medicine: Using the Dietary Guidelines Advisory Committee’s Report to Develop the Dietary Guidelines for Americans, 2020-2025. Dietary Guidelines website. Accessed January 22, 2021.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. Dietary Guidelines website. Published December 2020. Accessed January 22, 2021.

The human immune system consists of two major components: the innate and acquired immune systems. A person is born with an innate immune system as their first line of defense. This includes factors such as skin integrity, mucosal membranes and immune cells including natural killer cells, or NK. The acquired immune system, also called the adaptive immune system, includes T- and B-cells, which help the body develop an immune “memory” when exposed to viruses or immunizations.

Individual nutrient intake, including some vitamins and minerals, can affect the immune system by supporting healthy physical barriers in the skin and mucosal membranes, or by impacting the gut microbiome, innate immune system macrophage function (white blood cells that kill microorganisms) and adaptive immunity via T- and B-cell function. Certain nutrient inadequacies may impair the immune response, and micronutrients including vitamins A, C, D, E, B₆, B₁₂ and folate and the minerals iron and zinc influence all aspects of the immune system.

Data from the 2005–2016 National Health and Nutrition Examination Surveys revealed many Americans who are 19 or older may have usual intakes below the estimated average requirement of vitamins A, C, D and E, as well as zinc, from foods. Information from the National Institutes of Health’s Office of Dietary Supplements indicates that while nutrients including vitamins C, D and E and minerals such as zinc do help support immune function, the primary goal should be to prevent deficiency rather than taking more than the recommended amounts.

Nutrients, the Immune System and COVID-19
There is some evidence that the immune system is influenced by nutritional status and that malnutrition does increase risk of admission to the intensive care unit and mortality from COVID-19. However, less is known about the potential preventative benefits of individual nutrients on viral infections, including COVID-19. Developed by a panel of experts, the NIH’s report on treatment guidelines for COVID-19 includes information about zinc and vitamins C and D as adjunctive therapies, but much of that data is based on supplements rather than functional foods. The guidelines for vitamins C and D state that there is currently not enough data to recommend for or against their use in preventing or treating COVID-19. In the case of zinc, the data is lacking for or against its use as a treatment; however, the panel recommends against its use as a supplement in amounts above the recommended dietary allowance in the prevention of COVID-19, unless it is being administered during a clinical trial. A scoping review by the Academy’s Evidence Analysis Center found a lack of evidence regarding the efficacy of additional micronutrients or conditional amino acids such as glutamine or arginine in reducing the severity of disease in people infected with COVID-19.

Currently, there are no specific nutritional guidelines for those who have or are at risk for COVID-19. Medical nutrition therapy guidelines say registered dietitian nutritionists should provide care for those infected with COVID-19 to help optimize nutritional status and prevent malnutrition including screening for food insecurity and helping provide budget-friendly food options, when appropriate.

Market Trends for Functional Foods and Immune Support
Consumer sales for functional foods with proclaimed “immune-supporting” ingredients such as vitamin C, vitamin D, elderberry, beta-glucan, probiotics and antioxidant polyphenols have increased greatly since the COVID-19 pandemic began in 2020. This trend led to increased product claims — some illegal — such as statements about disease treatment.

Projections suggest global immunity-focused functional foods will grow by $170 billion between 2019 and 2023, reaching $1 trillion. Market research studies show that consumers are especially interested in foods rich in vitamins C and D, specifically due to fears of COVID-19.

A 2020 consumer market report revealed that 31 percent of consumers are taking more supplements as a result of the pandemic and 29 percent are consuming more functional foods and beverages, including fortified or enriched products, and increasing consumption of healthful foods such as whole grains, fruits, vegetables, plain bottled water and fruit or vegetable juices. When asked why they were increasing use of supplements and functional foods, their reasons included immunity, increased energy, general illness prevention and for digestion and microbiome support.

Regulatory Policies and Oversight
A study examining the term “immune boosting” on Instagram during the COVID-19 pandemic found that between April 15 and May 15, 2020, the use of the hashtag #immunebooster increased more than 46 percent. Researchers warn that, given the lack of evidence that specific products can enhance the immune system for protection against COVID-19, using these types of terms can be misleading to consumers.

The U.S. Food and Drug Administration and Federal Trade Commission have been addressing product label claims as they relate to the immune system and specific diseases such as COVID-19. Companies are not allowed to claim their product prevents, treats or alleviates signs or symptoms of COVID-19. Additional guidance provided by industry experts includes that companies should not make anti-inflammatory or anti-viral claims. This advice extends to social media, blogs, websites and product representatives or influencers.

Additionally, these experts advise companies and individuals to use caution with terms such as “boost,” “build,” “defend,” “therapeutic” or “protect” in regard to the immune system, and instead can claim immune or general health support. Further advice includes taking caution with using the hashtags #coronavirus or #COVID19 when referencing a product or health claim.

Potential Dangers of Supplemental Functional Foods
Many foods are functional in that they provide energy, protein or other nutrients to the body. Although there is no specific legal definition in the U.S., working definitions for functional foods have been used in the past by several organizations, including the Academy of Nutrition and Dietetics. According to the “Position of the Academy of Nutrition and Dietetics: Functional Foods,” published in 2013 and now retired, “the term functional foods is defined as whole foods along with fortified, enriched, or enhanced foods that have a potentially beneficial effect on health when consumed as part of a varied diet on a regular basis at effective levels based on significant standards of evidence.” Because many functional foods are fortified or enriched with nutrients beyond the recommended amounts, there is a risk of consuming more than the Dietary Reference Intakes of many nutrients, which could be problematic. For example, people who exceed the Tolerable Upper Intake Level for vitamin E (1,000 milligrams per day for adults) may experience an increased risk of bleeding or hemorrhagic stroke. Supplementing can be problematic as well. For instance, vitamin E supplements can interact with medications including anticoagulants and statins. Chronic intakes of supplemental zinc in high amounts can impair copper absorption, alter iron function and even reduce immune function — the opposite effect desired by many people taking additional zinc.

Role of the RDN
Registered dietitian nutritionists should be mindful of language used in education materials, blogs, websites and social media posts, as well as know what can and can’t be said about potentially immune-protecting foods or nutrients. Use caution with phrases such as “immune boosting,” which studies suggest could be fueling the spread of misinformation and misleading consumers.

Patients or clients may ask RDNs questions about functional foods and products to support the immune system or general health during the COVID-19 pandemic and beyond. Aside from conducting a nutrition assessment for potential micronutrient deficiencies, RDNs can take a whole foods approach, explaining how to obtain nutrients from food and when supplements may be needed, as indicated in the “Position of the Academy of Nutrition and Dietetics: Micronutrient Supplementation.” This position paper guides nutrition professionals to stay abreast of research regarding the efficacy of supplements and to educate and guide consumers on the appropriate and safe use of micronutrient supplements.

Nutrition professionals can refer to the Academy’s “Guidance Regarding the Recommendation and Sale of Dietary Supplements” for more information about regulatory, legal and ethical considerations and the “Scope and Standards for the RDNs and NDTRs Collection” in the Journal of the Academy of Nutrition and Dietetics.

For patients or clients interested in ways to protect their immune response, RDNs can share evidence-based guidance on lifestyle factors including recommendations for sleep, exercise and alcohol consumption. Studies show a direct connection between sleep and immunity, protecting both immune system maintenance and response when sleep is achieved in adequate amounts.

Research on how regular (three to five days per week, 20- to 60-minute sessions), moderate-intensity exercise modulates immunity shows promise for benefiting several aspects of the immune response. For adults who are of legal age and choose to drink alcohol, the 2020-2025 Dietary Guidelines for Americans specify a limit of one drink or less in a day for women and two drinks or less in a day for men on days alcohol is consumed. This can be an important piece of guidance given evidence that chronic, heavy alcohol intake can reduce immunity to both viral and bacterial infections.

RDNs are well-positioned to educate consumers on all aspects of dietary and lifestyle factors that help achieve optimal immune function.

References

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